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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS 2 mo Li 1 CIT <br /> OWNER NAME ( OWNER PHONE l'SL <br /> CONTRACTOR CONT . PHONE } <br /> 6 '52s . 5727 <br /> FIRE PERMIT <br /> REMOVAL(_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE bZZl TANK 39 1locjp O ( <br /> R RINSED �) METHOD W so^f RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST t` OR OTHER <br /> V VAPORS PURGED &N) METHOD AMOUNT USED (, cc L <br /> A <br /> P READING AT REMOVAL L . E . L . : O 02 : o-jb <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL , FIBERGLASS , OTHER ) <br /> 0 <br /> N TANK CONDITION ( GOOD , OR HOLES ) <br /> S <br /> T PIPE MATERIAL ( FIBERGLASS , OTHER ) FEET <br /> PIPE CONDITION ( GOOD , OR HOLES ) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> Trot.— clD 1 <br /> N G <br /> K <br /> S 1EXCAVATION SIZE ^ owX t�� X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE ` <br /> P P PT ` <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DE�P TO G . W . : FT . SAMPLING METHOD <br /> H <br /> 2 J4 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 />