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0 <br />SITE NAME <br />ADDRESS �,1 1 `�X �,\ �1 } <br />CITY iCC :•,_' e_ <br />OWNER NAME �c- �' �'� <br />OWNER PHONE <br />s is (�c fi <br />CONTRACTOR <br />CONT. PHONE <br /># �S l C) <br />FIRE PERMIT <br />REMOVAL ,� - CLOSURE IN PLACE <br />ORARY CLOSURE <br />INSPECTOR US�1 OIG : <br />DATE <) L <br />q(Q TANK # 39 .;O <br />R <br />RINSED (�7N) METHOD <br />-�7r, ��� <br />� RINSE AMOUNT'�-'ICgt,A <br />I <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST # <br />OR <br />OTHER <br />V <br />VAPORS PURGED CY%N) <br />METHOD` <br />� _ AMOUNT USED ? (� <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: <br />02: (U <br />0 <br />R <br />COMMENTS <br />TANK MATERIAL(ISTEEL, <br />FIBERGLASS, <br />OTHER) <br />C <br />0 <br />N <br />TANK CONDITION (GOOD, <br />OOZ2� HOLES) <br />S <br />T <br />PIPE MATERIAL STEEL <br />FIBERGLASS, <br />OTHER) <br />0 FEET <br />PIPE CONDITION (GOOD, <br />P60R HOLES) <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE <br />T <br />A <br />N <br />L� i . _ <br />/ A �ta,w <br />K <br />S <br />EXCAVATION SIZE <br />X X <br />YDS OF SOIL <br />A <br />M <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE <br />P <br />P <br />L <br />I <br />- <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION <br />X <br />X <br />YDS OF SOIL <br />DEPTH TO G.W.: <br />FT. <br />SAMPLING METHOD <br />H <br />2 <br /># HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <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 />