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PUBLIC HI rH SERVICES-ENVIRONMENTAL ALLTH DIVISION <br /> SITE NAME/ 'ADDRESS lq,v CITY <br /> 4 61 <br /> OWNER NAME,J Lj TOWNER PHONE 04 f <br /> CONTRACTOR//> - �J I CONT. PHONE ;7/t2 <br /> FIRE PERMIT <br /> R IOVAL_�L CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTO ' S DATE TANK 3 9 <br /> R RINSED /N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED ) I METHOD AMOUNT USED <br /> A <br /> P READING AT REMMOVAL I L.E.L. :/ 02: Ci <br /> 0 <br /> R COMMENTS ���� /�✓f �I?�� ��LC C� <br /> C I TANX MATERIAL (STEEL, =IB S, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POO HOLES) <br /> S - ) I-- i <br /> T PIPE MATER AL SEWTFIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, HOLES) <br /> DEP'T'H SOIL TYPE I OBSERVATION I SAMPLE T <br /> A _ <br /> � I <br /> I i <br /> S EXCAVATION SIZE V, X ��/ X�� YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE ( OBSERVATION ( SAMPLE <br /> P P I I I <br /> L i I i <br /> I P <br /> N E <br /> G � <br /> TRENCH D130NSION X X I YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 r HOURS SINCE DEWATERING: <br /> 0 <br /> ILLOTS SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> IFCLOSURE IN PLACE I MIXTURE: I VOLUME: i <br /> 11 <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />