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PUBLIC HE: 'H SERVICES-ENVIRONMENTAL F LTH DIVISION <br /> SITE NAME'( (��S ADDRESS ` E ,, erc (4421p I CITY <br /> OWNER N I OWNER PHONE 24 &c) _,32Z 3Z <br /> CONTRACTOR-RS CONT. PHONE if 433 --Do 0lo <br /> FIRE PERMIT t co _og <br /> R-EIIOVAL CLOSURE Iv PLACE TEMPORARY CLOSURE <br /> i <br /> INSPECTOR O b� DATE Q oZ TANK # 39 515831 <br /> R RINSED N) METHOD '(( ) RINSE AMOUNT_'Gn j <br /> I JV <br /> N RINSATE DISPOSAL SITE NV <br /> S " <br /> E MANIFEST # �5 OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD iU AMOUNT USm"L'jx �DS <br /> A I <br /> P READING AT REMOVAL L.E.L. : I1� 02 . ��YW / 1 <br /> 0 <br /> R COMMTENITS iv J^ Wo- - ' ' ,6 L 0r— <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) �r <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) at FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) A <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A <br /> K <br /> S EXCAVATION SIZE IO X X YDS OF SOIL tiZCJ <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 /> H <br /> 2 it HOURS SINCE DEWATERING: <br /> 0 <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 />