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PUBLIC Hj&LTH SERVICES-ENVIRONMENTAL F-EALTH DIVISION <br /> SITE NAMEI ADDRESS W CITY <br /> OWNER NAME- OWNER PHONE <br /> CONTRACTOR (_T I CONT. PHONE # aO a <br /> FIRE PERMIT <br /> REMOVAL CLOSURE N PLACE TEMPORARY CLOSURE <br /> v <br /> INSPECTOR DATE 11 S TANK 39 <br /> METHOD RINSE AMOUNT <br /> R RIT 3ED (YkN <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED dpN) I METHOD J AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 102: <br /> 0 <br /> R COM CENTS <br /> C TANK MATERIAL ( E FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, _ HOLES) <br /> S <br /> T PIPE MATERIAL , FIBERG S, OTHER) T FEET <br /> i <br /> j PIPE CONDITION (GOOD,K? R, HOLES) <br /> DEPTH SOIL TYPE (OBSERVATION ISLE s <br /> v C <br /> N <br /> S EXCAVATION SIZE X SO X 2i YDS OF SOIL <br /> A iM DEPTH ( SOIL 'r'YPE ( OBSERVATION ( SAMPLE <br /> L P I / l/ - S <br /> N P <br /> G <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: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: I VOL U1 : <br /> EFi 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />