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PUBLIC HEFTTH SERVICES-ENVIRONMENTAL FT ' LTH DIVISION <br /> SITE NAME ADDRESS _I CITY <br /> OWNER NAME TOWNER PHONE <br /> CONTRACTOR ' `` CONT. PHONE # '� <br /> FIRE PERMIT # 14- 1 <br /> REMOVAL CLOSURE 21 PLACE TEMPORARY CLOSURE <br /> INSPECTOR ��1� ' �� �_ ,/-�. <br /> < DATE i r c,-„ TANK # 3 9 i' �- / <br /> R RINSED ,/.2�) I 'IHODr 'Gf� 1oi���=_ RINSE AMOUNT <br /> N RINSATE DISPOSAL SIT:' <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) iHETHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL ( L.E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> LT�k PIPE MATERIAL (STEEL, FIBERGLASS ER) # FEET <br /> PIPE CONDITION (GOOD.i--POOR, HOLES) <br /> DEPTH SOIL TYPE 1OBSERVATION SAMPLE # <br /> T - I <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE (OBSERVATION SAMPLE # <br /> P P _ <br /> L I �� rye I�y�i- I�Li - '•- =,,L-" i������ :v�- L, SG <br /> I P �ti✓J ' L.'/G,% � CJI _ CG>iL �'"�.LGGL=G2 r iUil �/ — ? <br /> G <br /> 140 "'J'9_- r J ��L7c ;�iSc'cu.%F- 1; ;vii G .- <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> LLOTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: •' `kyr �' <br /> CLOSURE IN PLACE KXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />