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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HFALTH DIVISION <br /> SITE NAME G `" <br /> Pow ADDRESS X131 w�� CITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR SCv CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 39 tiC(c4(o� <br /> R RINSED LfIN) METHOD �40-t RINSE AMOUNT (ps <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD L,CC� AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : �o <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, OLES 4 les .ica.- <br /> S <br /> T PIPE MATERIAL T FIBERGLASS, OTHER) FEET + <br /> PIPE CONDITION (GOOD, Q�, HOLES) �l <br /> C7. OSICi,'� <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A lXll i ,tn_ <br /> N <br /> K Nc s <br /> S EXCAVATION SIZE X X YDS OF SOIL <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 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> 1' CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />