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PUBLIC HEA,H SERVICES-ENVIRONMENTAL 1. .LTH DIVISION <br /> SITE NAME ADDRESS CITY <br /> OWNER NAME �� A, 1a T OWNER PHONE J 577 <br /> CONTRACTOR AES CONT. PHONE <br /> G UxrJnl c �L <br /> FIRE PERMIT AP <br /> REMOVAL_ CLOSURE LY PLACE T=ORARY CLOSURE <br /> INSPECTOR ��� � DATE /d/r5�c� TANK r 3 9 7 ' ?-7 -iL <br /> R RINSED (Y/N) METHOD ���i � RINSE AMOUNT 95-,;7I <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 COMMEN'T'S <br /> C TANK MATERIAL (�3TfEL, FIBERGLASS, OTHER) <br /> 0 � , <br /> N TANK CONDITION (GOOD, _�, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE s <br /> T .. p �A'L Or iQ TA+ G TJ QST <br /> At4wl WAP PP.y i tou'- <br /> N <br /> K <br /> S EXCAVATION SIZE-3v" X ^ 30- X /1' 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 I YDS OF SOIL <br /> DEPTH TO G.W. : FT. I SAPLDLING M=OD <br /> A <br /> 2 4 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: / tiG'c v? SAI-m- LZRS NAME: /*7IL <br /> / Ga <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />