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PUBLIC HEAL SERVICES-ENVIRONMENTAL H-_.TH DIVISION <br /> SITE NAME �UG6c/NIi <br /> OWNERADDRESS 6 /Iy. p,��� ¢�/� CITY `�K� , <br /> OWNER PHONE # Z 6 9 U y��� 4-/ � 2311 <br /> �� ieK�.v G <br /> CONTRACTOR^ U ��N ONT. PHONE # Z!� 1 SZ <br /> rcoFIRE PERMIT # Iql' f S <br /> REMOVAL_ <br /> CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORG,/j��j�t <br /> DATE !/TANK # 39 <br /> R RINSED Y N) THOD pL //vs RINSE AMOUNT/7 J <br /> I <br /> N RINSATE DISPOSAL SITE <br /> SOR OTHER <br /> E MANIFEST # <br /> V VAPORS PURGED ((I)N) METHOD /)4y GZ AMOUNT USED 4 O O L4S <br /> AO2 : S b <br /> P READING AT REMOVAL L.E.L. : <br /> R COMMENTS E (_ -7�- !C - j <br /> C TANK MATERIAL ( TEE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL, ( TEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION GOO POOR, HOLES) <br /> DEPTI SOIL TYPE OBSERVATION SAMPLE # <br /> T � i S. OG✓ilI- O O/Z <br /> A <br /> NAlo i1 <br /> S EXCAVATION SIZE X _ X �� YDS OF SOIL / <br /> ASAMPLE # <br /> M DEPTH SOIL TYPE OBSERVATION <br /> P <br /> L <br /> I v c( 3 <br /> N r . O U� U2 i <br /> G TRENCH DIMENSION lkIo / STN YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> l / <br /> H <br /> 2 # HOURS SINCE DEWATERING: Sp � S <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: (y�, p SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />