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PUBLIC HEAJ&j SERVICES -ENVIRONMENTAL WTH DIVISION <br />SITE NAME,,j,G( <br />TZ�DRESS <br />CITY �. <br />OWNER NAME a t 5 <br />OWNER PHONE <br />CONTRACTOR, 'C / <br />CONT. PHONE <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE �� p�G TANK # 39 /;Z& (p <br />R <br />I <br />RINSED Y ) <br />METHOD <br />RINSE AMOUNT 5s <br />N <br />S <br />RINSATE DISPOSAL SITE <br />E <br />MANIFEST # OR OTHER <br />V <br />A <br />VAPORS PURGED ©/N) <br />METHOD <br />AMOUNT USED <br />P <br />0 <br />READING AT REMOVAL <br />L.E.L.: 0 <br />02: �06U <br />R <br />C <br />O/ <br />COMMENTS `-' <br />TANK MATERIAL((STE , FIBERGLASS, OTHER) 3 <br />N <br />S <br />TANK CONDITION GOOD OOR, HOLES) <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />� <br />T <br />A <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />N <br />K <br />I _ <br />w °o <br />S <br />A <br />EXCAVATION SIZE X(p X <br />YDS OF SOIL 1 2� <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />LLOTHER <br />H <br />2 <br />0 <br />DEPTH TO G.W.: 71(o it FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />FCLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />zi <br />