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p PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAMEC ADDRESS LS.6 CITY <br /> OWNER N ( OWNER PHONE # Z r <br /> CONTRACTOR A CONT . PHONE iE <br /> FIRE PERMIT t <br /> REMOVAL_�� CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR, DATE TANK 39 ( JVLUn 07_ <br /> R RINSED ChN ) METHOD f 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 I L . E . L . : O 02 : . O 'Io <br /> 0 <br /> R COMMENTS <br /> er <br /> C TANK MATERIATE FIBERGLASS , OTHER ) <br /> O <br /> N TANK CONDITION ( GOOD , OOR HOLES ) <br /> S <br /> T PIPE MATERIAL C3g IBERGLASS , OTHER ) FEET ,1L) -P4I <br /> PIPE CONDITION ( GOOD , HOLES ) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> AT 1 00. 5 Pt <br /> N <br /> K <br /> S EXCAVATION SIZE 44alff c L X YDS OF SOIL 2 ?57� <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 . : FT . SAMPLING 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 />