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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME <br /> 4-4-.9 CC ADDRESS CITY <br /> OWNER NAME OWNER PHONE # • aOf <br /> CONTRALTO CONT. PHONE # <br /> FIRE PERMIT # <br /> REMOVAL- CLOSURE IN PLACE TEMPORARY CLOSURE <br /> L <br /> INSPECTOR DATE 7 18 S TANK # 39 <br /> R RINSED dgN) METHOD .•�-M �� bJ` �, N.Lv RINSE AMOUNT 3b <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST Qr77_ltd OR OTHER <br /> V VAPORS PURGED ( )N) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 0°70 02: <br /> 0 0 <br /> R COMMENTS <br /> C TANK MATERIAL , FIBERGLASS, OTHER) <br /> O _!7 <br /> N TANK CONDITION (GOOD,d D HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL ER , OTHER) # FEET <br /> PIPE CONDITION (GOOD' HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T `y <br /> AAA <br /> N 5 <br /> R <br /> S EXCAVATION SIZE t, Z X j qL_ 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 MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />