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PUBLIC HEALIP SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ;PE. D/� ADDRESS QA S L � CITY <br /> OWNER NAME PZr0 OWNER PHONE # a7 U 9 9 p�G r TGv:J <br /> CONTRACTOR C CONT. PHONE # 0 <br /> FIRE PERMIT # �L <br /> -3 <br /> 7 <br /> REMOVAL CLOSURE IN PLACE q TEMPORARY CLOSURE <br /> INSPECTOR k,� t5h t DATE���' I "/ TANK # 39 / 0 1 S 0I2_ <br /> R INSED (Y N) METHOD %tt RINSE AMOUNT a00 QQ <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> VrF-.A!%DING <br /> ORS PURGED {Y ) METHOD AMOUNT USED <br /> A <br /> P AT REMOVAL L.E.L. : O 02 : ) �� <br /> O <br /> R MENTS <br /> C TANK MATERIAL STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD., OOR HOLES) r U Ste oL /UO-pq,5 b�� h o ev✓ <br /> S <br /> T PIPE MATERIAL TEE , FIBERGLASS, OTHER) # FEETt <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> K n <br /> S EXCAVATION SIZE X _!J_ YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E J <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: S P <br /> LABORATORY:6,00 & � SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTUR VOLUME: <br /> LI— <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />