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t'uBlLLC HEALTH SERVICES–ENVIRONMENTAL IHEALTH DIVISION <br /> SITE NAME <br /> .7— <br /> ADDRESS c�vv lG viGio� CITY <br /> OWNER N �� OWNER PHONE j4 7z <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT <br /> REMOVAL ^ CLOSURE IY PLACE ! TEMPORARY CLOSURE � <br /> ;r <br /> INSPECTOR EJ € DATE 9 : TANK 39 17 q l Z E <br /> � I <br /> RINSED Y/N) METHOD�,,—,y RINSE AMOUNT <br /> S RINSATE DISPOSAL SITE �Errn{6erdy J <br /> E MANIFEST 04 /2j OR OTHERF <br /> V VAPORS PURGED METHOD pzY AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 : <br /> R COMMENTS <br /> C TANK MATERIAL t!!�__ HER <br /> FIBERGLASS, OT )Ill �p <br /> 0 r i <br /> N TANK CONDITION (GOOD, 9 HOLES) <br /> S <br /> T PIPE MATERIAL tqEEL IBERGLASS, OTHER) i; x FEET I <br /> PIPE CONDITION (GOOD, OOR HOLES) <br /> DEPTH SOIL TYPE OBSERVATION i+ ( SAMPLE <br /> T <br /> A ^ /� r`a opfe, v ScrG- two 17,C-Z—A - f <br /> N ` v vow—' v S016: i3tSCv�c�Yr " A7——81 /4� f <br /> K <br /> S EXCAVATION SIZE -q7 X ^ZStr X tZ YDS OF SOIL 3oa <br /> T5, <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE „ <br /> P P <br /> L I '� I <br /> I P k ;{ <br /> G al I <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 ALrm�. SAMPLERS NAME:L <br /> I G h:sr <br /> CLOSURE IN PLACE MIXTURE: VOLUME <br /> - <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> i <br /> i <br />