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PUBLIC HEALTH <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />ADDRESS <br />CITY <br />SITE NAME �� <br />OWNER NAME �� c_i� �, <br />OWNER PHONE <br />CONTRACTOR k! ._ i-; <br />CONT. PHONE <br />FIRE PERMIT # <br />v` Z i ff <br />REMOVAL %: CLOSURE IN PLACE Y CLOSURE <br />INSPECTOR L j41 , v �0. DATE I C)�q TANK # 39 �Z_ t 'c 3 d` <br />R RINSED C�)/N) METHOD %�-.,,�� iZ��� RINSE AMOUNT <br />I <br />N <br />, <br />RINSATE DISPOSAL SITE <br />S <br />E <br />V <br />MANIFEST OR OTHER <br />VAPORS PURGED (2yN) METHOD 2 AMOUNT USED w <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: <br />02: L S <br />0 <br />R <br />COMMENTS <br />C <br />TANK MATERI(STEEL„ FIBERGLASS, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD P R—, HOLES) <br />S <br />T <br />PIPE MATERIAL((STEEL, FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, (PLOb , HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />T <br />A <br />ks z <br />N <br />K <br />S <br />EXCAVATION SIZE X X <br />YDS OF SOIL <br />A <br />M <br />P <br />P <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />L <br />I <br />I <br />N <br />P <br />E <br />G <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br />x <br />2 <br />if HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />L 11 <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />