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PUBLIC HAIaLTH SERVICES - <br />DIVISION <br />SITE NAME 7 -e)e—ll ADDRESS <br />CITY <br />OWNER NAME ��G \ OWNER PHONE # <br />CONTRACTOR CONT. PHONE # <br />FIRE PERMIT <br />REMOVAL k CLOSURE IN PLACE <br />TEMPORARY CLOSURE _ <br />INSPECTOR J I OSI o%c` DATE TANKS 39 <br />I RINSED (Y/N) METHOD �— �— <br />i 01-� RINSE AMOUNTZ�' <br />N RINSATE DISPOSAL SITE <br />S Ql'\ZOS Ci1Viu 0��llci\tc- <br />E MANIFEST #' <br />OR OTHER <br />V VAPORS PURGED (Y/N) METHOD <br />A _-0 /U AMOUNT USED JCS <br />P READING AT REMOVAL L.E.L.: <br />0 02: <br />R COMMENTS <br />C TANK MATERIAL (STEEL, ERG OTHER) <br />0 <br />N TANK CONDITION GOOD POOR, HOLES) <br />S <br />T PIPE MATERIAL (STEEL, IBERGLAS , OTHER) # FEET". S <br />i <br />PIPE CONDITION (GOOD, P00 , HOLES) <br />ll e8 r b <br />DEPTH SOIL TYPE OBSERVATION <br />T w SAMPLE <br />S <br />EXCAVATION SIZE X j (G � X <br />A <br />YDS OF SOIL iiC y� u�F <br />M <br />DEPTH SOIL TYPE OBSERVATION <br />P <br />P <br />SAMPLE # <br />L <br />I <br />Y do% rUc ��ce b <br />I <br />P <br />N <br />E <br />G <br />TRENCH DIMENSION NSA X <br />X <br />YDS OF SOIL <br />H <br />DEPTH TO G.W.:5b-iOU FT. <br />SAMPLING METHOD <br />2 <br /># HOURS SINCE DEWATERING - <br />0 <br />OTHER SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE <br />IN PLACE MIXTURE: <br />VOLUME <br />EH 23-0043 <br />(REV 2/23/94) PROVIDE SITE <br />MAP <br />0 <br />' <br />