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PUBLIC HEA' i SERVICES-ENVIRONMENTAL F `LTH DIVISION <br /> SITEPSME ADDRESS ((, G, ICITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR 1A F)ob/ '-Zee/ CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR 7 " r DATE "q TANK # 39 <br /> R RINSED /N) METHOD _�� �, ( RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOODOOR, HOLES) uSto 9''Pi <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) #p FEET <br /> Li- <br /> OO <br /> PIPE CONDITION (GOOD, R HOLES) cf -e- b-ck'd-J <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N DIV 11 g4gjL <br /> K <br /> S EXCAVATION SIZE 14� X X _� YDS OF SOIL �6 3 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P , O <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 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: 4i S f <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />