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w <br /> PUBLIC HEAAL SERVICES-ENVIRONMENTAL HAM DIVISION <br /> SITE NAME,�"� MAR JADDRESS *675 /5 4 L � <br /> , #7V- CITY <br /> OWNER NAME -li y I V I �4 OWNEP PHONE i `ZZD e7O 7 <br /> CONTRACTOR ICCNT. PHONE J <br /> FIRE PERMIT 9 b7_ l F-51 <br /> REMOVAL_ CLOSURE =4 PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATEIa-q-j$ TANK .4 391 6 <br /> R RINSED N) M=HOD S RINSE AMO / lap- <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR 0THER <br /> Ta <br /> VAPORS PURGED (Y/N) METHOD (AMOUNT USED <br /> READING AT REMOVAL L.E.L. : C2 : <br /> COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) `( `uI 1-"'AV /0 <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) F N 2�- <br /> s <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE IOBSE.RVATION SAMPLE <br /> T I I I E <br /> A S I W <br /> N I I <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE (OBSERVATION SAMPLE € <br /> P P I I <br /> L I <br /> I P <br /> N E I I <br /> G <br /> TRENCH DIMENSICH X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 i <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLEKRS NAME: I <br /> i CLOSURE IN PLACE I 'MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />