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PUBLIC HEALTH SERVICES-ENVIRONMENTAL, HEALTH DIVISION <br /> SITE NAMES c Co ADDRESS /� <br /> cue r` yC, CITY <br /> OWNER NAME-© Cv (OWNER PHONE J4 7 -b <br /> if � � s <br /> CONTRACTOR/ w" % Ln <br /> [CONT�. PHONE , <br /> `3 <br /> FIRE PERMIT r !syV�-- I <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR rj'y� p �1-� TANK 0 39 <br /> R RINSED fN) METHODf <br /> I � L RINSE AMOUNT 3 7,3 <br /> N RINSATE DISPOSAL SITE ?O/C-C- s <br /> S <br /> E MANIFEST , 77 5 OR OTHER <br /> V VAPORS PURGED (9N) METHOD u;j" <br /> A IAMOUNT USED <br /> P READING AT REMOVAL L.E.L. : <br /> 0 Q 02 : 3 <br /> R COMMENTS r <br /> `CT-ANY MATERIAL TES FIBERGLASS, OTHER) / irr <br /> O U-Lr <br /> N T_NNK CONDITION (GOOD, OO , HOLES) <br /> ! S <br /> T PIPE MATERIAL, ( TE FIBERGLASS, OTHER) FEET �(1, <br /> PIPE CONDITION (GOOD, POOR, OLE <br /> T DEPTH SOIL TYPE OBSERVATION SALE <br /> A 0. <br /> N Q <br /> S ^ / <br /> S EXCAVATION SIZEIS <br /> X XYDS OF SOIL <br /> /00 <br /> M DEPTH SOIL TYPE OBSERVATION <br /> P P SAMPLE , <br /> L T z' I s a 'I <br /> I P S / <br /> N E <br /> G <br /> TRENCH DIMENSION X X <br /> YDS OF SOIL <br /> H DEPTH TO G.W. :`^ FT. SAMPLING METHOD <br /> 2 .74 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: Pa.' I SAMPLERS NAME: /3,J/ Ske_� <br /> CLOSURE IN PLACE MI " VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />