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PUBLIC HEATH SERVICES-ENVIRONMENTAL H.v TH DIVISION <br /> SITE NAME ADDRESS SDOp E / CITY <br /> Z c, Sto c /i' <br /> OWNER NAME IOWNER PHONE <br /> CONTRACTOR I CONT. PHONE # <br /> FIRE PERMIT # "! - ' 3 <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR L��( DATE y TANK # 39 <br /> R RINSID /N) METHOD <br /> I RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> AV VAPORS PURGED ) METHOD �, , <br /> AMOUNT USED <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STEEL FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OOR HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) £ FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH ( SOIL TYPE IOBSERVATION SAMPLE <br /> A <br /> N <br /> K 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 P <br /> N <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEETH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 if RS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: I SAMPLERS NAME. <br /> CLOSURE IN PLACE I MIXTURE: VOLIIME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />