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PUBLIC HEA ""H SERVICES -ENVIRONMENTAL N_ LTH DIVISION <br />SITE NAMER,ADDRESS <br />�6/,J / <br />CITY Z'd <br />OWNER NAME <br />OWNER PHONE <br />CONTRACTOR s <br />CONT. PHONE # 3 <br />FIRE PERMIT # D3 YY - <br />YOVAL <br />OVA CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE 3� TANK # 3 9 <br />R <br />I <br />RINSED ) <br />METHOD c� T RINSE AMOUNT <br />N <br />S <br />E <br />RINSATE DISPOSAL SITES pQe <br />MANIFEST # OR OTHER <br />V <br />A <br />VAPORS PURGED (Y'N) <br />METHOD <br />AMOUNT USED <br />P <br />O <br />READING AT REMOVAL <br />L.E.L.: _j <br />02: <br />R <br />COMMENTS ,'�j,!j �-Q d -- <br />C <br />0 <br />TANK MATERIAL STEEL FIBERGLASS, OTHER) <br />N <br />S <br />TANK CONDITION GOOD POOR, HOLES) <br />T <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />T <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />S <br />A <br />A <br />K <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 SAMPLE # <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />LLOTHER <br />H <br />2 <br />0 <br />DEPTH TO G.W.:__LLL FT. <br />SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />