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PUBLIC HEA-,,i SERVICES-ENVIRONMENTAL HF „TH DIVISION <br /> SITE NAME)'1gN)L11ADDRESS <br /> r-nG Sin CITY SiG~c � <br /> OWNER NAME TOWNER PHONE <br /> CONTRACTOR a CONT. PHONE if <br /> FI_RE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR 6&f DATES-� J ' `� TANK # 39 5 <br /> R RINSED Y N) METHOD RINSE _ UNT fJ <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> LP <br /> VAPORS PURGED Y N) METHOD vv C¢ (AMOUNT USED <br /> READING AT REMOVAL L.E.L. : 02: <br /> CONlMiENTS <br /> C TANK. MATERIAL STEEL FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) � FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH ( SOIL TYPE ( OBSERVATION ( SAMPLE <br /> FNT ` Qc / <br /> SEXCAVATION SIZE X X YDS OF SOIL <br /> A — <br /> MDEPTH ( SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I I I <br /> N E I <br /> G <br /> TRENCH DI=SION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 if HOURS SINCE DEWATERING: <br /> l[o <br /> OTHER SAMPLE: s' Fl I <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />