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PUBLIC HEALTH SERVICES—ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAMED^>^ ADDRESS Zyc v ��. iii CITY <br /> OWNER NAME OWNER PHONE # (X(9) <br /> CONTRACTOR CONT. PHONE # /sg� <br /> FIRE PERMIT # <br /> REMOVAL__�J _ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �la�l DATE 7 TANK # 39 / 556 L <br /> R RINSED AM'I'N) RINSE AMOUNT <br /> I I <br /> N RINSATE DISPOSAL SITE Nom AZ <br /> OCT L <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED C6/N) METHOD��e� � AMOUNT USED CI <br /> A <br /> P READING AT REMOVAL L.E.L. 02 : /. 7 <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL 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 # <br /> T <br /> A <br /> N <br /> K <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 - 60, 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: ;AMPLERS NAME: adc <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />