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PUBLIC HEAT" H SERVICES -ENVIRONMENTAL H'-' T.,TH DIVISION <br />SITE NAME�&d4 eZU <br />ADDRESS <br />CITY <br />OWNER NAME 0 <br />OWNER PHONE # <br />CONTRACTORS--� <br />CONT. PHONE 3 <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE Z� 5 TANK <br /># 39 <br />R <br />I <br />N <br />S <br />RINSED CIA) METHOD _ <br />RINSATE DISPOSAL SITE:555 <br />RINSE AMOUNT <br />_ <br />E <br />MANIFEST # <br />OR OTHER <br />V <br />A <br />VAPORS PURGED (Y)N) <br />METHOD , <br />AMOUNT USED <br />P <br />0 <br />R <br />READING AT REMOVAL <br />COMMENTS <br />L.E.L.: l 3 <br />02: / �o <br />C <br />0 <br />TANK MATERIAL STEEL, <br />FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION GOOD <br />POOR, HOLES) <br />T <br />PIPE MATERIAL (STEEL, <br />FIBERGLASS, OTHER) <br /># <br />FEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />A <br />T <br />A <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE # <br />w <br />EXCAVATION SIZE X X <br />YDS <br />OF SOIL DoT <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />DEPTH SOIL TYPE <br />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: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: _T <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />