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PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME C ADDRESS �ZSaI AAF <br /> CITY <br /> d Q <br /> j OWNER NAME , OWNERPHONE i <br /> CONTRACTOR CONT . PHONE q � b5Z <br /> FIRE PERMIT <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE , g TANK 39 <br /> R RINSED UN ) METHOD lV RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (ON ) METHOD AMOUNT USED ? <br /> A <br /> P READING AT REMOVAL L . E . L . : of 02 : Z s� <br /> 0 n <br /> R COMMENTS <br /> C TANK MATERIALC25TE FIBERGLASS , OTHER) <br /> 0 <br /> N TANK CONDITION ( GOOD , OR OLES ) <br /> S <br /> T PIPE MATERI_AL ST , FIBERGLASS , OTHER ) # FEET <br /> PIPE CONDITION ( GOOD , POOR HOLES ) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T D "t: <br /> A ,Llo 4c+-- <br /> N <br /> K <br /> S EXCAVATION SIZE 3LOX 42 G 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 /> 1 DEPTH TO G . W . : FT . SAMPLING METHOD <br /> x <br /> j 2 HOURS SINCE DEWATERING : <br /> 0 <br /> I1 OTHER SAMPLE : <br /> LABORATORY : SAMPLERS NAME : <br /> CLOSURE IN PLACE MIXTURE : VOLIIME : <br /> EH 23 - 0043 ( REV 2 / 23 / 94 ) PROVIDE SITE MAP <br />