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PUBLIC HEAT"'H SERVICES -ENVIRONMENTAL H` -LTH DIVISION <br />SITE NAME <br />ADDRESS <br />CITY <br />OWNER NAME ` <br />OWNER PHONE # <br />33(�-0 S <br />CONTRACTOR �/ <br />CONT. PHONE # <br />_ 8 3� 3 <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE <br />TEMPORARY CLOSURE <br />INSPECTOR <br />DATE ,3 3��Qrj <br />TANK # 39 <br />R <br />I <br />N <br />S <br />E <br />RINSED (gN) METHOD -r- �� RINSE AMOUNT �S <br />� <br />RINSATE DISPOSAL SITE <br />MANIFEST # OR OTHEd- <br />V <br />A <br />P <br />0 <br />R <br />VAPORS PURGED ON) <br />READING AT REMOVAL <br />COMMENTS 6,,l 611, �e ja"o.,e, <br />METHOD u� AMOUNT USED �00 <br />L.E.L.: 9 02: a l� <br />t e Q <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 />TioFEET <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />S <br />A <br />T <br />A <br />K <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE # <br />_ <br />EXCAVATION SIZE 3 X X `I <br />YDS OF SOIL 1 Zip <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 <br />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 />11 - <br />MIXTURE:7 <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />