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4 PUBLIC HEA SERVICES-ENVIRONMENTAL F_ ',LTH DIVISION <br /> SITE NAME G. ADDRES i ,j S, �_*Z4 CITY-r4dG .tl�w <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR i`m rp c_6 r CONT. PHONE # <br /> FIRE PERMIT # � <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR B A4 DATE TANK it 39 <br /> R RINSED LVN) METHOD }tt RINSE AMOUNT <br /> I _ <br /> N RINSATE DISPOSAL SITE P P, C_ s <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y N) METHOD Lam- AMOUNT USED <br /> A " <br /> P READING AT REMOVAL L.E.L.o � 02 : , <br /> R COMMENTS D / 7D /7D <br /> C TANK MATERIS EEL FIBERGLASS, OTHER lob <br /> 0 <br /> N TANK CONDITION GOO POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SRO7 E S u Rc <br /> T <br /> A <br /> NAl <br /> g <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I - <br /> I P f <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. • FT. SAMPLING METHOD <br /> H i <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: /p <br /> LABORATORY: G1020 ARC, 4,- C at SAMPLERS NAME: <br /> JLCLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />