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PUBLIC Ht`-`�rH SZRVICES-ENVIRONMENTAL '>' J,TH DIVISION <br /> SITE NAME 1 J;LDDRESS 2e-6- CITY S i <br /> OWNER NAME OWNER PHONE t <br /> CONTRACTOR SA ICONT. PHONE , Zj - <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE �/jl TANK ,t 3 9 <br /> R RINSED dY ) METHOD RINSE AMOUNT L7 <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGIDN) IMETHOD AMOUNT USED ,3 Zr <br /> A <br /> P READING AT REMOVAL L.E.L. : � 02: j <br /> O <br /> R CONII4ENT S L („5 074-'T-4 <br /> C TANK MATERIAL (��, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD <br /> S � <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE j <br /> T i c, crc I <br /> A <br /> N I I <br /> K I ► I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P I i <br /> L I i I <br /> I P <br /> N E I <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> CArH <br /> 2 24 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: e r-�- SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />