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i <br /> PUBLIC HATH SERVICES-ENVIRONMENTAL LALTH DIVISION <br /> SITE NAME CoO� �` ADDRESS' <br /> 1�1�0 S,vp.\�v �Av�C CITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR s- CONT. PHONE <br /> ' FIRE PERMIT <br /> REMOVAL CLOSURE IN -PLACE TEMPORARY CLOSURE <br /> INSPECTOR �W�Spy�p�� DATE TANK 39 <br /> G <br /> R RINSED (-t, /N) METHOD ..,5p.�r�P RINSE AMOUNT 1pcjG <br /> I C - <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST f Z�-\\L ,-a OR OTHER <br /> V VAPORS PURGED (Y�N) METHOD S \C� AMOUNT USED �5 <br /> A <br /> { P READING AT REMOVAL L.E.L. : 02: :k <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL (STEEL, FIBERGLASS, OTHER) SZCral- <br /> 0 <br /> N TANK CONDITION D, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL, F�B­] GLAS THER) FEET <br /> } <br /> PIPE CONDITION 00 , POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION ISAMPLE J <br /> T <br /> A �. <br /> N <br /> K <br /> s <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE , <br /> P p <br /> L I S� � _ �•-�G,�a-r � <br /> _. I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> i <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 /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />