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PUBLIC HE"-"H SERVICES-ENVIRONMENTAL t -NLTH DIVISION <br /> SITE NAMEADDRESS F,57>0 yG7b� �je/J CITY GpO� <br /> OWNER NAME EG OWNER PHONE 36�_ X755 <br /> ICONTRACTOR �'J CONT. PHONE <br /> j FIRE PERMIT , <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR X5:7-oe _vim DATE /O/Z�g TANK } 39 / '7[� _-s <br /> * 15 � <br /> R RINSED 5/N) METHOD lr, Z ��x- RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE ��rG <br /> S <br /> E MANIFEST OR OTHER <br /> JR <br /> CJ <br /> VAPORS PURGED (Y/N) METHOD fJ� AMOUNT USED ��,q' <br /> READING AT REMOVAL L. E.L. : �j02 : <br /> COMMENTS <br /> i <br /> C TANK MATERIAL ( FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 00 HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET L /oS l7v�lL <br /> PIPE CONDITION (GOOD OOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T _ <br /> A 1oc7orP o 50,E f7.scoccR9rnrc,i�� E`er-5- r ' <br /> N 1 �O O/.b o o[- /SCvc+Xiv r rp GI <br /> K <br /> S EXCAVATION SIZE X -3o _ X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P <br /> N E <br /> 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 /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />