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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME nt nc +w� 41 ADDRESS 6DSCS i s n Q CITY <br /> �bIG ViS 0 t cxkTo� <br /> OWNER NAME tin e�til OWNg2 PHONE Ji <br /> 7 3 <br /> CONTRACTOR SE:0co CONT. PHONE <br /> FIRE PERMIT Af <br /> REMOVAL X CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR Yo��,(2,k, DATE -/I 9S TANK 0 39 l2.S9 <br /> R RINSED 6Y N) METHOD se RINSE AMOUNT <br /> I ,I <br /> N RINSATE DISPOSAL SITE /t�'reC1b�eU <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED �jY/N) METHOD (b, Ice, ', AMOUNT USED �b <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : U <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, (j00 HOLES) "a UJ uE uS+ <br /> S <br /> T PIPE MATERIAL CSTE FIBERGLASS, OTHER) $ FEET <br /> PIPE CONDITION (GOODPOO , HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> Cl (c-'a'" OcGo� 6_#- i2 TIL I <br /> N 2 Loaw Mo mor rKZ. <br /> N <br /> tL <br /> S EXCAVATION SIZE Zs' X I O X r 4 YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE 0 SAMPLE ` <br /> P P <br /> L I �oe( ne over e <br /> I P c do S Ie <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 ig HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> • <br /> 0 <br />