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PUBLIC H;_,,TH SERVICES-ENVIRONMENTAL `ALTH DIVISION <br /> SITE NAMES�� w S ADDRESS Z��l W I CITY <br /> A2 L70.4' Za,/ <br /> OWNER NAME s I OWNER PHONE <br /> CONTRACTOR v� CONT. PHONE <br /> FIRE PERMIT a4 ry -rig <br /> REMOVAL CLOSURE MT PLACE TEMPORARY CLOSURE <br /> INSPECTOR V-� DATE 71yI� TANK t 39 <br /> R RINSED (Y/N) METHOD �r r� RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE c/ <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED T) METHODAM <br /> / CUNT USED <br /> bH <br /> A ��y Cf err yl G <br /> P READING AT REMOVAL L.E.L. : 02: /v <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL. ( E=, IBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR OLES) <br /> S <br /> T PIPE MATERIAL (STEEL, F=ERGLASS OT:Drtt) # FEET <br /> PIPE CONDITION (GOOD OLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE <br /> T /H SO 9G O vDaE' oc ae4av! /— r <br /> N � � <br /> K i <br /> S EXCAVATION SIZE/7'5V X - 35 X-7,Z YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P <br /> N _ <br /> G <br /> TRENCH 0nmgSION X X ( YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING =CD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: `�y <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />