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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME � �_ ADDRESS ��ct� Gy . L.pO/ CITY C�yp <br /> OWNER NAME IOWNER PHONE 7Z0C> <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL/ _ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR ° DATE TANK # 39 / 5f,�- <br /> R RINSED ) METHOD RINSE AMOUNT l w�Iii <br /> I <br /> N RINSATE DISPOSAL SITE (q V,n &,V <br /> S r <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED MN) METHOD p,¢y AMOUNT USED �Zt7�L <br /> A <br /> P READING AT REMOVAL L.E.L. : / % 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL ($jFIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, eCM 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 5� Ehr <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X _Few X ^ 2� 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: 5;14*44- SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />