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OWNER NAME �' �'-�- OWNER PHONE J4 <br /> CONTRACTORS C CONT. PHONE <br /> FIRE PERMIT ,At �� l <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE e <br /> INSPECTORI,�'t ski GC. DATE 3J��- �, TANK , 39 Jr� <br /> R RINSED (Y N) OD RINSE AM UNT as <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST 24 OR OTHER <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED 1.6-5 <br /> A <br /> P READING AT REMOVAL L;E.L. : 02 : <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL �TE�E�LFIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION GOOD; POOR, HOLES) U'�S` <br /> S <br /> T PIPE MATERIAL TE FIBERGLASS, OTHER) ,4 FEET <br /> PIPE CONDITION <t2OD POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE ,# <br /> T -64-+ o dye <br /> A I 11.6 S <br /> N <br /> K <br /> S EXCAVATION SIZE X X =DSF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE i <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 METHOD1-r S� <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: $-�bG K i !e <br /> LABORATORY: 6gD Arokf I,Cxk SAMPLERS NAME: P-ctj aoeveot e' <br /> CLOSURE IN PLACE MIXT=: __TVOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP �K 3 X <br />