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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME On ADDRESS CITY <br /> OWNER NAME OWNER PHONE <br /> CONTRACTOR S CONT. PHONE (;7 <br /> FIRE PERMIT -7 <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR"'1)e4w64f' DATE TANK 0 3 9 <br /> R RINSED (Y METHOD RINSE AMOUNT <br /> I - <br /> N RINSATE DISPOSAL SITE <br /> S <br /> "E 11MANIFEST # OR OTHER <br /> I. <br /> V VAPORS PURGED METHOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: <br /> 0 <br /> 1 R IICOMMENTS <br /> C TANK MATERS!!� E FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD,(iOKLES) <br /> S <br /> PIPE MATERIAL (gjjE,>FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOO D��00R ' HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> -k4 <br /> A <br /> N <br /> K rf,-r Aw. 6 A-6Qy&M7a.J_1j6 e�nX_- <br /> S EXCAVATION SIZE 36 X -� X-a YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P <br /> N <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. _7SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> LLOTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> IF CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />