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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME Vj8 COd ADDRESS - ,,y_ �L 11"al C <br /> OWNER NAMEQ_�,. OWNER PHONE # <br /> CONTRACTOR CONT. PHONE # 2 <br /> r <br /> FIRE PERMIT # <br /> REMOVAL X CLOSURE IN PLACE TEIPORARY CLOSURE <br /> INSPECTOR DATE 9 TANK it 39 <br /> R RINSED ) METHOD . (,tJ RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # C'7�9 64210 OR OTHER <br /> V VAPORS PURGED �T) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : © 70 02: <br /> 0 <br /> R COMME14TS_ <br /> C TANK MATERIAL , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOODHOLES) <br /> S !gm I <br /> T PIPE MATERIAL ( FIBERGLAS OTHER) # FEET <br /> PIPE CONDITION (GOOD; OOR, OLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T crt3 <br /> A ¢T, t <br /> NAir <br /> R qr <br /> S EXCAVATION SIZE 4L X IcE 1 X 13 YDS OF SOIL 100 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P C%^A QlfCA4 A600— PEE w y <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 MIXTORE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />