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PUBLIC HEA` 3 SERVICES-ENVIRONMENTAL, y'- DIVISION <br /> DIVISION <br /> SITE NAMEG. ADDRESS TY S <br /> OWNER NAME OWNER PHONE'# <br /> 4 CONTRACTORm ' CONT. PHONE , <br /> FIRE PERMIT , <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTORDATE 3- TANK 39 .2– <br /> R <br /> 2R RINSED (Y ) METHOD--b:��, RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> EMANIFEST f OR: OTHER <br /> V VAPORS PURGED ON) METHOD AMOUNT USED <br /> A ' <br /> P READING AT REMOVAL L.E.L. : us,,, 02: a <br /> O <br /> R COMMENTS <br /> i <br /> C TANK MATERI STEEL FIBERGLASS, OTHER) �O 2 <br /> 0 <br /> N . TANK CONDITION OD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL EEL, FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD., POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATIO 1�PL SAMPLE # <br /> T i <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE X X YDS F SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> r <br /> N E <br /> I <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: n <br /> LABORATORY: c-,oD SAMPLERS NAME: <br /> IF—CLOSURE IN PLACE .MIXTURE: ..---7-- VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP I <br />