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PUBLIC HEA' SERVICES-ENVIRONMENTAL F7 '-TH DIVISION <br /> SITE NAME ��a� L l ADDRESS,4,�,,S l , L"cl CITY <br /> OWNER NAME Sher O l OWNER PHONE # Z0g q3( - 31�, � �O <br /> CONTRACTOR Uj CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL �� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �/ DATE ( /49 4 TANK ,; 39 <br /> R RINSED &/N) METHOD t O "`'�� ��� RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S �crlG <br /> E MANIFEST # Z OR OTHER <br /> V VAPORS PURGEDY�/N) METHOD � '� /41, �a AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : -3& � � 02: 'o: 3 <br /> R COMMENTS <br /> C TANK MATERIAL TE , FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION GOO , POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) ,' FEET <br /> Pt* -r �r <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A <br /> N <br /> K ut <br /> S EXCAVATION SIZE X 3a 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. : 50 FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> ti <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> ',H 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> { <br />