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PUBLIC H`LTH SERVICES-ENVIRONMENTAL- HEALTH DIVISION <br /> SITE NAME �� ADDRESS ! CITY <br /> OWNER NAME /, I OWNER PHONE <br /> CONTRACTOR " ' CONT. PHONE <br /> FIRE PERMIT if 9� _ 7io I & <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE 2/�/9(, TANK 39 `�✓'`� -p ID 600 UL <br /> R RINSED ( N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y N) ME'T'HOD � �. AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> 0 / <br /> R COMMENTS -fa , `ta4 <br /> C TANK MATERIAL (STEEL FIBERGLASS, OTHER) ��( (v�� <br /> 0 <br /> N TANK CONDITION GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL,(FIBERGLASS OTHER) # FEET 3 <br /> PIPE CONDITION (GOOD, POOR, HOLES) y-h 6-t2)Q.(i� <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE i <br /> T 72 <br /> A !¢C <br /> N fLrtido. 0 iCJLU-ea-2.ed <br /> K E5 <br /> S EXCAVATION SIZE 3S X _ X J Z YDS OF SOIL !� <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P lC Q67 <br /> L I <br /> I P o�[ — <br /> N E � <br /> G .� <br /> TRENCH DIMENSION X (c� X O 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: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> i <br />