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PUBLIC HEAJTH SERVICES-ENVIRONMENTAL VIIALTH DIVISION <br /> SITE NAMESm Y� Llv ADDRESS CIT <br /> OWNER NAME Vr <br /> (OWNER PHONE # M J 2lr <br /> CONTRACTOR NJ I CONT. PHONE <br /> FIRE PERMIT ;r <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK ;p 39 <br /> R RINSED (Y ;D THOD I RINSE AMCUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST ) OR OTHER <br /> V VAPORS PURGED (Y JN) (METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> O <br /> R COMMENTS <br /> C TANK MAT (STE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, .00 HOLES) <br /> S <br /> T PIPE MATERIAL FIB G OTHER) FEET <br /> PIPE CONDITION (GOOD, .00 HOLES) <br /> DEP'T'H I SOIL TYPE OBSERVATION I SAMPLE � <br /> T 471 <br /> - I _ -/3• <br /> A &747I i <br /> N - _ I -f- <br /> K I I <br /> EXCAVATION SIZE X O X YDS OF SOIL <br /> S L Q1 f <br /> A <br /> M DEPTH SOIL TYPE (OBSERVATION ( SAMPLE T <br /> P P <br /> L I <br /> I P SS 2 <br /> N E <br /> G <br /> r21lTRENCH OnCENSION X X ( YDS OF SOIL <br /> DEPTH TO G.W. : FT. ( SAMPLING METHOD <br /> 24 HOURS SINCE DEIRATERING: <br /> OTHER SAMPLE:: <br /> LABORATORY: SAP^?LZ_RS NAME: <br /> CLOSIIRE IN PLACE LLT;TTIIRE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />