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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME 13 ADDRESS t pJ CITY <br /> OWNER NAME sa-- OWNER PHONE # <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR J DATE Ti �� TANK # 3 9 <br /> R RINSED (Y/ METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED ) METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL T , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, 00 , HOLES) <br /> S <br /> T PIPE MATERIAL , FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOOD, 00 HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> A <br /> S EXCAVATION SIZE -�w X,,36- X � rr 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 /> LABORATORY: SAMPLERS NAME:LU <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />