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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS . n.t3j, CITY <br /> OWNER NAME OWNER PHONE J <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT ` 0.5 <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR Cj I DATE 5- TANK if 39 �(a [� Q <br /> R RINSED (� N) METHOD RINSE AMOUNT S <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E JIMANIFEST OR OTHER <br /> V VAPORS PURGED {WN) METHOD .-1 AMOUNT USED <br /> A - <br /> P READING AT REMOVAL L.E.L. : 02: 17 <br /> 0 <br /> R COMMENTS <br /> C TANK MATERI {STEL- FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD00 HOLES) <br /> S _ <br /> T PIPE MATERIAL TEE FIBERGLASS, OTHER) FEET - � <br /> PIPE CONDITION (GOOD, . OOR, 'HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE , <br /> A <br /> K <br /> S EXCAVATION SIZE t�_rX L � '^ YDS OF 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 METHOD <br /> H <br /> 2HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTIIRE: VOLUME: <br /> EH 23--0043 (REV 2/23/94) PROVIDE SITE MAP <br />