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PUBLIC HEjJTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> FSITE NAME ADDRESS ln4/t2CITY <br /> WNER NAME ( OWNER PHONE //�/� <br /> CONTRACTOR I CONT. PHONE -(J/ de'; �!J <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATEf� TANK 39 0 1 <br /> R RINSED (Y gTHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST 34 �1 � ' L OR OTHER <br /> V VAPORS PURGED ( /N) (METHOD � AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : <br /> 0 <br /> R COMMENTS <br /> ; <br /> C TANX MATERIAL (ITE FIBERGLASS, OT..R) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PT_PE MATS-' l (STEEL, 3ERG OTMER) I � FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> SOIL _E ( OBSERVATION SAML9LE <br /> DEPTH ( <br /> T 1 4/// lVrAr I-F _ <br /> A <br /> N <br /> l _ /U71 - / <br /> S EXCAVATION SIZE X -.T� % / Z' YDS OF SOIL Uri <br /> A <br /> M ( DEPTH SOIL TYPE ( OBSERVATION ISAMPLE T <br /> P P 1 <br /> L T- <br /> I P f I f7 , -p fv <br /> G E <br /> 1 J I <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. ( SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: j <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE ffXTURE: I VOLUME: <br /> &H 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />