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ijUbLZc HEALTH SERVICES--ENVIRONMENTAL;e HEALTH DIVISION <br /> SITE NAME�- �- ADDRESS pU/G v�G a� CITY <br /> li �e� J 9 <br /> OWNER N � OWNER PHONE 7Z- <br /> CONTRACTOR CONT. PHONE # '� <br /> FIRE PERMIT 4, y rs <br /> it Z7 �r <br /> REMOVAL, CLOSURE IN PLACE P TEMPORARY CLOSURE <br /> INSPECTOR � � DATE TANK :39 <br /> L{ 2 <br /> I <br /> R RINSED 07ii) METHOD--7;5,�GF �' RINSE AMOUNT 3?� <br /> I <br /> N RINSATE DISPOSAL SITE ' ' ms's <br /> S ^�`j <br /> E MANYFEST OR OTHER <br /> V VAPORS PURGED (-WN) METHOD x,27 r�L AMOUNT USEDi5*-,-lb, <br /> A <br /> P READING AT REMOVAL L.E_L. : .1r Q2 : <br /> 0 <br /> R COMMENTS 11 <br /> i} 7 <br /> C TANK MATERIAL T , FIBERGLASS, OTHER)' <br /> 0 <br /> N TANK CONDITION (GOOD, , HOLES) - <br /> S <br /> T PIPE MATERIAL, TE FIBERGLASS, OTHER)! ,r 'FEET <br /> PIPE CONDITION (GOOD, 00 , HOLES) i <br /> DEPTH SOIL TYPE OBSERVATION a ' :. _ SAMPLE ,# i <br /> + J SwtFASL�oB�4r. O$S�vis'i fdv,.'rL - ^lSB•6 <br /> N ~ I J Gid o'�� sT• r j� T -3 r7 r <br /> K <br /> s I <br /> S EXCAVATION SIZE X ^Z,(- 'X ^r2 ;YDS OF SOIL ^ 30b <br /> A " <br /> M DEPTH SOIL TYPE OBSERVATION :� SAMPLE , <br /> P P <br /> L I �i I <br /> I P <br /> N E F <br /> G <br /> TRENCH Dri'.EENSION `' 3o` X ^�� X1 3 I YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 i <br /> OTHER SAMPLE: <br /> LL ,G <br /> LABORATORY: SAMPLERS NAME: <br /> „ F <br /> CLOSURE IN PLACE MIXTURE: VOLUME: f <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />