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PUBLIC HEALTH -ENVIRONMENTAL HEALT�3 DIVISION <br /> ADDRESS <br /> SITE NAME `�� z� 5. S 1, 7 CITY <br /> OWNER NAME aQ�n J ` OWNER PHONE <br /> CONTRACTOR CONT. PHONE <br /> e yv1 r o _ . <br /> FIRE PERMIT <br /> REMOVAL ✓ CLOS URE ri PLACE _ TEMPORARY CLOSURE <br /> INSPECTOR a 5r`� <br /> DATE TANKi 39 J Y$ 1 <br /> R RINSED (DN) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL 'SITE <br /> S OR OTHER <br /> E MANIFEST <br /> V VAPORS PURGED <br /> AMOUNT. USED <br /> AREADING AT REMOVAL L.E.L. : oD/� 02: <br /> P G✓�I ��C7 <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL STEEL FIBERGLASS, OTHER) G �� �e5c' <br /> N TANK CONDITIO (GOOD _OUR, HOLES) <br /> S <br /> T PIPE MATERIAL ST FIBERGLASS, OTHER) r�,tFEET <br /> PIPE CONDITIO ('GOOD, POOR, HOLES) E <br /> DEPTH SOIL, TYPE OBSERVATIONSAMPLE 44 <br /> T 004w O ` �a o✓4 n Z S <br /> A I <br /> N <br /> K " C r. <br /> S EXCAVATION IZE' X <br /> Jv X 3 - YDS OF SOIL <br /> AS <br /> AMPLE <br /> t M DEPTH SOIL °.TYPEOBSERVATION <br /> P P <br />> L I <br /> I P I ✓G dry v o <br /> N E <br /> GON X f-- X YDS OF SOIL <br /> TRENCH OnCOSI <br /> DEPTH TO G <br /> -W. : FT. SAMPLING METHOD <br /> t H <br /> 2 HOURS SINCE DEWATERING: .: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: �ep Y1 G I A`,'l SAMPLERS NAME:� JC�lk/ <br /> CLOSURE IN PLACE MIXTURE: �^ ;; VOLUME:;; <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP ._. <br /> k <br /> I' / <br />