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PUBLIC H SERVICES-ENVIRONMENTAL TH DIVISION <br /> SITE NAME t, ADDRESS .30 1ST S• Zj2CITY <br /> OWNER NAME J OWNER PHONE # jp � <br /> CONTRACTOR 1LZ L CONT. PHONE # /_ <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR � �' 3 :ZDATES fj 4 TANK # 39 / 7 , <br /> R RINSED N) METHOD RINSE AMOUNT 6 <br /> I I .�eA 22 <br /> NRINSATE DISPOSAL SITE <br /> 1� <br /> S �1 <br /> E MANIFEST # 57`' �' OR OTHER 4f <br /> V VAPORS PURGED N) METHOD AMOUNT USED , <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL FIBERGLASS, OTHER) <br /> O / A <br /> N TANK CONDITION o , POOR, HOLES) <br /> S <br /> T PIPE MATERIAL E , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, POOR, HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T ! o �(c <br /> N <br /> K 77 <br /> S EXCAVATION SIZE X 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 <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 /> 1JL__ LABORATORY: SAMPLERS NAME:IF �� <br /> CLOSURE IN PLACE TMi VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />