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PUBLIC HEAL'T'H SZRVICE5– r:NVT_HONMr'NTA7 HEAL'T'1 U1-/ 1SSON � i r <br /> SITE I%� rYAr/ \ l ADDRESS f� CG i CITY <br /> OWNER NPS aWN,"ta PHONE <br /> C <br /> O <br /> N <br /> T <br /> R.46CTOCONT . PHONE <br /> EIRE PERMIT <br /> REMOVAL CLOSURE: 19 PLACE TE *lPORARY CLOSURE <br /> e <br /> LiSPECTOR �/. DP mr ��!' 7i�! '4•'7K T 3 9 <br /> R RINSED ��jN) T21O L e RZTTSr AMOUNT / 3 <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E Y=7EST # OR OTHER <br /> V VAPORS PURGED :(`i ) m=OD eZ AMOUNT USED <br /> A <br /> P READING AT REMOVAL I L . E _ L . : 102 : / <br /> R COMMENTS <br /> C T_xNX MATERIAL STEEL . =MMLASS , OTHER) O <br /> 0 i <br /> N TANK CONDITION ( GOOD , POOR , HOLES ) <br /> S a , <br /> T PIPE MAT `( STS. r. �E.RG'LASS , OTHER)� ^Ei^_' <br /> 912E CONDITION ( GOOD , (P0OR HOLES ) 17 <br /> DEPTH I SOIL TYPE I OBSERVATION ! I SA�L9LE r <br /> T / < Si I ' •lYmwri QUn8n n dr, <br /> N 2/ 7 % h > oto Ut o n T <br /> X I I <br /> I I <br /> S EXCAVATION SIZZ X (� X / I YDS Or SOIL <br /> A IM_ DEPTH ( SOIL TYPE ( OBSERVATION SAMPLE r - <br /> D O <br /> LI <br /> _ I <br /> P I <br /> N E <br /> I I <br /> G <br /> TRENCH D121ENSION X ( YDS OF SOIL <br /> DEPTH TO G . W . : 3J�f ET . ( SAMPLING METHOD <br /> H <br /> 2 T HOURS SINCE DEWATERIVG : <br /> 0 <br /> OTHER SAMPLE : <br /> LABORATORY : G,250 AW A, L/ m7ef- A, { -k S2MPLr= N2ff—p : _� ! (f <br /> CLOSURE IN PIA- CZ I MI:=URE : I VOLUME' : <br /> ZE 23 - 0043 (REV 2 / 23 / 94 ) PROVIDE SITE MIA2 � J <br /> j . <br />