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PUBLIC HEAT -7 SERVICES -ENVIRONMENTAL H TiTH DIVISION <br />SITE NAME <br />ADDRESS <br />Q� <br />CITY <br />OWNER NAME /f <br />OWNER PHONE <br /># 3:3 O/� /� <br />CONTRACTOR ss S <br />CONT. PHONE <br />r <br />FIRE PERMIT # <br />REMOVAL CLOSURE IN PLACE <br />TEMPORARY CLOSURE <br />INSPECTOR94 l:/::(z �_ DATE 3 l <br />Q 5 TANK # 39 /7C !A <br />O Z- RoL <br />R <br />I <br />N <br />S <br />E <br />RINSED (91f) METHOD <br />RINSATE DISPOSAL SITE <br />MANIFEST # OR <br />RINSE AMOUNT <br />PQ <br />OTHER <br />V <br />A <br />VAPORS PURGED (Y)N) <br />METHOD <br />/� <br />AMOUNT USED <br />�Sd <br />P <br />0 <br />R <br />READING AT REMOVAL L.E.L.: locl- 02: Z°/U <br />COMMENTS <f Co � <br />C <br />TANK MATERIAL (S7EL)FIBERGLASS, <br />OTHER)0 <br />N <br />S <br />TANK CONDITION(GOOD POOR, HOLES) <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, <br />OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />S <br />A <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE <br /># <br />' <br />EXCAVATION SIZE X X <br />YDS OF SOIL <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 <br />SAMPLE # <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />LLOTHER <br />H <br />2 <br />0 <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: 7, <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />