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PUBLIC HEAT-TH SERVICES-ENVIRONMENTAL HVXLTH DIVISION <br /> SITE NAM C <br /> 7ADDRESSCITY <br /> OWNER NAME �L¢ L OWNER PHONE 5 S <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT ` <br /> REMOVAL_ CLOSURE IN PLACE. TEMPO Y CLOSURE <br /> INSPECTOR DATE 2 ,�'�' TANK 1 3 9 4-3 Z_ C� <br /> R RINSED N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (DN) METHOD lee _ I5e� AMOUNT USED 350 <br /> A <br /> P READING AT REMOVAL L.E.L. : 0 rj 02: <br /> 0 <br /> R COMMENTS /moi/tel . 47 <br /> C TANK MATERIAL (STEEL, FIBERGLASS; OTHER) 61 <br /> O <br /> N TANK CONDITION GOOD, OOR, HOLES) <br /> S <br /> T PIPE MATERIAL 'STEEL FIBERGLASS, OTHER) It FEET <br /> PIPE CONDITION GOOD, OOR, HOLES) <br /> F <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> A $ <br /> N <br /> K <br /> a <br /> S EXCAVATION .SIZE X SD X l =DSOF SOIL �� 3 <br /> A <br /> M DEPTH SOIL! TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I 47�t <br /> I P r <br /> N E <br /> G <br /> TRENCH DIMENSION — X _ _ X YDS OF SOIL <br /> DEPTH TO G.W. : 755 FT. SAMPLING METHOD <br /> H <br /> 2 HOURS 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 />