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PUBLIC HEAL SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME F r /1'10 ADDRESS oa S CITYShGl�7ZM� <br /> OWNER NAME P E. d P14i r OWNER PHONE # � G rI� 9 IvE_ e'?LL , <br /> CONTRACTOR S Ftfl C U CONT. PHONE D <br /> FIRE PERMIT # l�, -3 <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORLT. _131`( .3 DATE ,1-aa-q4� TANK # 39 / a /.5 Q _ <br /> R RINSED (Y N) METHOD RINSE AMO T <br /> I t . <br /> N RINSATE DISPOSAL SITE ` <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y N) METHOD C� AMOUNT USED 7J <br /> A <br /> P READING AT REMOVAL L.E.L. : O 02: 7 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERI (STEEL FIBERGLASS, OTHER) <br /> N TANK CONDITION GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL OjEE FIBERGLASS, OTHER) # FEET <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N N <br /> K <br /> S <br /> EXCAVATION SIZE X _LD X YDS OF SOIL : / S3 <br /> A 11e <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P i i <br /> N E NA <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. :__6 � FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: N /p -/a d4 3 <br /> 0 <br /> OTHER SAMPLE: 'Spq, 6 pG D ¢ <br /> LABORATORY: G� L�� SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />