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PUBLIC HEI H SERVICES-ENVIRONMENTAL H LTH DIVISION <br /> SITE N ADDRESS � ' ITY <br /> OWNER NAME4eAAy6t O (OWNER PHONE _ <br /> CONTRACTOR CONT. PHONE q3a -o ro <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR A tiler( DATE 0 ja)OV TANK 39 rl5s3c, <br /> R RINSED ( N) METHOD RINSE AMOUNT- IEn <br /> I ;NN <br /> N RINSATE DISPOSAL SITEAVVA& N V <br /> S nn <br /> E MANIFEST # VI OR OTHER <br /> V VAPORS PURGED Y N) METHOD ' AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : • 0 02. f r <br /> O . <br /> R COMMENTS -to JLVW ca .o k-- <br /> * <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) D <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) N <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T i . <br /> A lcjN 1 -3 <br /> N 00 <br /> K <br /> ttm�dltdbugdhYU S <br /> S EXCAVATION SIZE X -7X T, YDS OF SOIL ti25 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> I <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 i <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />