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PUBLIC HFALTH SERVICES-ENVIRONMENTAL "`=H DIVISION <br /> SITE NAME ADDRESS &_Alm <br /> CITY ��� r <br /> OWNER NAME OWNER PHONE x! <br /> :rm et <br /> CONTRACTOR CONT. PHONE , <br /> FIRE PERMIT , 3 <br /> REMOVAL^ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR C DATE TANK , 39 <br /> R RINSED (Y&D METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGEDY <br /> A / ) i METHOD AMOUNT USED �. <br /> P READING AT REMOVAL L.E.L. : 02: <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL S E , FIBERGLASS, OTHER) <br /> O <br /> N TANK CONDITION (GOOD, - R HOLES) <br /> S - <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTH=) FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> T <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> A 5 - <br /> N ' <br /> K <br /> S EXCAVATION SIZER 1Z X _ YDS OF SOIL <br /> A ' <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE j <br /> P P <br /> L I <br /> I P ��' <br /> 44 <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> H <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> 2 , HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> i <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />