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PUBLIC HEALTH-JERVICES-ENVIRONMENTAL 1HEALTH DIVISION <br /> SITE NAME ADDRESS CITY o^ 1 <br /> ^ ; a <br /> OWNER N \ L l� I OWNER PHONE <br /> e <br /> CONTRACTOR CONT. PHONE ` S 2`/ 6 S <br /> FIRE PERMIT <br /> REMOVAL ✓ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �� DATE .f 6 TANK 0. 39 ? Lq <br /> R RINSED C?N) METHOD 3 RINSE AMOUNT 3�l <br /> I <br /> N RINSATE DISPOSAL '.SITE <br /> S <br /> E MANIFEST , OR OTHER <br /> V VAPORS PURGED ) METHOD �� AMOUNT USED <br /> _� <br /> P READING AT REMOVAL L.E.L. : 02: J? did <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL STEEL, FIBERGLASS, OTHER) <br /> /O pCxJ cplcs c l <br /> 0 <br /> N TANK CONDITID (GOOD POOR, HOLES) <br /> S <br /> T PIPE MATERIAL ST , FIBERGLASS, OTHER) ' FEET CJ <br /> PIPE CONDITION OOD OOR, HOLES) <br /> DEPTH SOIL- TYPE OBSERVATION SAMPLE <br /> T <br /> A <br /> N ,} <br /> K <br /> S EXCAVATION SIZE, X / Z 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 f <br /> G <br /> TRENCH DIMENSION X X r YDS OF SOI-Fs— <br /> DEPTH TO G.W. : —FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: : <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: Ca fr"�i c' T JlG 4� SAMPLERS NAME: �./ <br /> CLOSURE IN PLA =l <br /> CE MIXTURE: VOLUME: ' <br /> .k <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> . iF <br />