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PUBLIC HEA-'TH SERVICES-ENVIRONMENTAL FAITH DIVISION <br /> SITE NAMES ADDRESS CITY Gd,p <br /> OWNER NAME OWNER PHONE j 6Fj- ? 755 <br /> CONTRACTOR es A) ST CONT. PHONE 67 <br /> FIRE PERMIT �r��JEO ///jp/q� GO✓� / FSE <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE re/ TANK # 39 <br /> R RINSED N) METHOD /rPG_E J RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S �1 <br /> E MANIFEST �JZ�% t�— OR OTHER <br /> TRV VAPORS PURGED (Y/N) METHOD AMOUNT USED y /y <br /> A <br /> P READING AT REMOVAL L. E. L. : 02 : <br /> O <br /> COMMENTS <br /> C TANK MATERI TE , FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION.'(GOOD, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET o O S o <br /> PIPE CONDITION (GOOD, O , HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE $ <br /> T <br /> A v iccoccaq�-ioa c�r1 rf <br /> N '7 f o o So. ar it -d <br /> R <br /> S EXCAVATION SIZE !V4 X 30 X fly 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: F <br /> CLOSURE IN PLACE MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />