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PUBLIC HEAI _r SERVICES-ENVIRONMENTAL HT TTH DIVISION <br /> SITE NAME�Oµ ADDRESS S / CITY <br /> OWNER NAMEd� G� OWNER PHONE <br /> CONTRACTOR -s CONT. PHONE # S Y -7-3 <br /> FIRE PERMIT V= vC 0 0 <br /> REMOVAL ✓ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR � DATE Z'�3 e - TANK # 39fb/ <br /> R RINSED & U) METHOD3x i I, �� c� RINSE AMOUNT`39©, <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V A VAPORS PURGED (Y/N) METHOD � lC AMOUNT USED j U(_)-+ `b <br /> P READING AT REMOVAL L.E.L. : <br /> R COMMENTS <br /> C TANK MATERIAL QSTit FIBERGLASS, OTHER) <br /> 0 ( <br /> N TANK CONDITION (GOOD, P0032� HOLES) <br /> S <br /> T PIPE MATERIALSTEEL FIBERGLASS, OTHER) # F ET <br /> 11 PIPE CONDITION (GOOD, OOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE } <br /> T <br /> A % c` r w 0clorT ' <br /> N <br /> C)ricr <br /> K <br /> S EXCAVATION SIZE 3 t X LL�y5 X iy` YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P M <br /> L I oc.wt o u Iti{ i J - <br /> I P �� •l Dov. S <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 # 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 />