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PUBLIC HFIA34 SERVICES-ENVIRONMENTAL 04TH DIVISION <br /> SITE NAME t ' C" tiG ADDRESS `'3S3 [ �i FTYCI <br /> OWNER NAME ,�� ct__ OWNER PHONE ,?�� <br /> CONTRACTOR .t fIP� CONN'. PHONE <br /> FIRE PERMIT <br /> REMOVAL x CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �kq DATE �p�gi 'ct TANK # 3 9 <br /> R RINSED N) METHOD -X RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S n Q <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED YJ'N} METHOD `� AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STEEL, FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD,(BOOR, HOLES} <br /> S <br /> T PIPE MATERIAL ST FIBERGLASS, OTHER) , FEET .' eyAf <br /> PIPE CONDITION (GOOD, 00 HOLES) <br /> DEPTH SOIL TYPE OBSERVATION ( SAMPLE <br /> A Sl. tt <br /> N Oc(0 r <br /> K <br /> S EXCAVATION SIZE X 21 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 DIN:ENSION 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 MIXTURE= VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE' MAP <br />