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PUBLIC HEATH SERVICES-ENVIRONMENTAL h. ,LTH DIVISION <br /> SITE NAME S'l;''aK,4lA4C 7- ADDRESS CITY <br /> I <br /> OWNER NAME OWNER PHONE (bg) S-77- lZP aj <br /> CONTRACTOR660EUL- CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR � � <br /> DATE -r'%rs�cy� TANK 3 9 ? �j�j% �'K <br /> R RINSED '�/N) =OD oo_( , RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (YIN) (METHOD ,`/ - TGA AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : P/ 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL ,-FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, OR HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T ' 2rOche Sloe 1 !c sc, <br /> N <br /> K <br /> S EXCAVATION SIZE„ X ^ 30 X %Z- YDS OF SOIL / goy <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE if <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> Ll TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 if HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: �� ��«, � SAMPLERS NAME: <br /> /01yIF � <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />