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I i! <br /> .PUBLIC HEAT T SERVICES-ENVIRONMENTAL H"kLTH DIVISION <br /> SITE NAME �_v ADDRESS oo lvrGZ� J CITY L" <br /> OWNER NAM$ OWNER PHONE 7 <br /> CONTRACTOR CONT. PHONE r z,6F- '117Z <br /> FIRE PERMIT <br /> REMOVAL - - CLOSURE IN PLACE TEMPORARY CLOSURE <br /> A r <br /> INSPECTOR Ae--tZ- DATE 5�v7 6r`' TANK # 39 <br /> R RINSED ff;PN) METHOD �i� - aS RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> E MANIFEST # OR OTHER E <br /> V VAPORS PURGED &N) METHOD pAy �„G ;f AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : GgG- i';i <br /> 3: 02 : Dyt <br /> 0 r <br /> R COMMENTS <br /> II <br /> C TANK MATERI E L FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD,-, OOR OLE ) <br /> S .:E <br /> MATERIAL STEEL FIBERGLASS OTHER # FEET <br /> T PIPE MA (STEEL, , } <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> II <br /> DEPTH SOIL TYPE OBSERVATION m SAMPLE # <br /> ,P <br /> T <br /> A <br /> N <br /> K <br /> i1 1 <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I r <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING;IMETHOD <br /> II <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> a <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: aAL' �C�� <br /> SAMPLERS NAME: <br /> [— <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> s <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP; <br />