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PUBLIC HEAT SERVICES-ENVIRONMENTAL H3 TH DIVISION <br /> SITE NAME � I ( ADDRESS CITY0 <br /> OWNER NAME � �\� ! \ OWNER PHONE # Z09 gi3I - 3(0 ,q� <br /> CONTRACTOR �j CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR h��c� DATE ( TANK # 39 7;(QO C�3 <br /> R RINSED &/N) METHOD 3L-> �"0 "` �w� RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # Z O 4�4/ 2 18. OR OTHER <br /> V VAPORS PURGED CY)/N) METHOD Dr 'cc 1411 G L AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02 3 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIALTE , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION GOO , POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> 7 <br /> PIPE CONDITION (GOOD, POOR, HOLES) �r�^osro� wigs <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A U <br /> N s <br /> K ` <br /> S EXCAVATION SIZE X 3 0 X = F <br /> DS 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. _7SAMPLING 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 />