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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTti UIV15-Lori <br /> SITE NAME ADDRESS ;VCO CITY <br /> i�riylYL . <br /> OWNER N OWNER PHONE <br /> CONTRACTOR CONT. PHONE # 0 r S <br /> FIRE PERMIT sla2t&.:=d2o=- �, � iz,z <br /> o yl�. <br /> REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE .5.a .9 f TANK f 39 Z 0-5 <br /> R RINSED (9N) METHOD ,� !.t-G RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST OR OTHER <br /> V VAPORS PURGED (9N) METHOD ' AMOUNT USED f,350# <br /> A � <br /> P READING AT REMOVAL L.E.L. : Q � !G 02 : ° <br /> 0 <br /> R COMMENTS '� /k <br /> C TANK MATERIAL (STEEL, FIBERGLASS OTHER) <br /> 0 <br /> N TANK CONDITION ; GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL STEEL FIBERGLASS, OTHER) Tf FEET <br /> PIPE CONDITION ' (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE i` <br /> T e/57a <br /> A r <br /> N <br /> K <br /> S EXCAVATION SIZE CSL X 50 X /�� _ YDS OF SOIL f71CO 3 <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE i# <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> L . I i <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> i <br />