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PUBLIC HAWTH SERVICES-ENVIRONMENTAL !tETH DIVISION <br /> [SITE NAME 5 ADDRESS Zyyg )���r , CITY <br /> NER NAMEOWNER PRONE S3?j_NTRACTOR a`L CONT. PHONE <br /> FIRE PERMIT 6/1/4i5r <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR�EV%-,- k DATE-7121-9g>'�TANX # 39 5p 5 ' Z <br /> R RINSED E } METHOD ��iOf� �r F RSNSE AMOUNT rSo C, <br /> I <br /> N RINSATE DISPOSAL SITEySiDE <br /> S <br /> E MANIFEST P <br /> OR OTHER <br /> V VAPORS PURGED WN) I METEOD (..` AMOUNT USED s ly <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: S iU <br /> O <br /> R COMMENTS <br /> C TANK MATER= EEL' FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, <� HOLES) <br /> S <br /> T PIPE MATM= ($TL'.L, S, OTT ) Ir = T <br /> I <br /> ( PIPE CONDITION (GO POO , HOLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE 34 <br /> T n4,G v odeL a �.d 0 <br /> A <br /> R , <br /> q e 5�/fr�r ra:e' 9oi AiSt � <br /> $ EXCAVATION SIZE. X ,:, X YDS OF SOIL Z5 <br /> A <br /> M DEPTH SOIL TYPE I OBSERVATION SAMPLE # <br /> P P ` o c A <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIlMENSION X X I YDS OF SOIL <br /> DEPTH TO G.W. : ET. SAMPLING METHOD <br /> H <br /> 2 jf HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> ESI 23-0043 (REV 2/23/94) PROVIDE SITE MA-D <br />