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PUBLIC HEA,H SERVICES-ENVIRONMENTAL H,. �TH DIVISION <br /> SITE NAME ' C- ADDRESS ��� �4 rlAglvno-lt� CITY <br /> OWNER NAME ( OWNER PHONE # <br /> CONTRACTOR j CONT. PHONE # <br /> FIRE PERMIT # _ 13 <br /> REMOVAL_X_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR 16JUDATE,' I_ TANK # 39 <br /> RRINSED Y N) I M.°THOD z RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> VAPORS PURGED (Y N) (METHOD (AMOUNT USED <br /> [ 2. <br /> READING AT REMOVAL L.E.L. : 02: <br /> REC0M1TS <br /> C 11 TANK MATERIAL S` TEts� FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATER_IALL (STEEL, FIBERGLASS, OTHER) # FEET <br /> Ll PIPE CONDITION (GOOD, POOR, HOLES) <br /> 11 DEPTH ( SOIL TYPE ( OBSERVATION ( SAMPLE # <br /> T <br /> K <br /> l S v <br /> N }I <br /> I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ( SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I PIg <br /> N <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />