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PUBLIC EEC SERVICES-ENVIRONMENTAL IOLTH DIVISION <br /> 00 f Z, <br /> SITE NAME ADDRESS I fl CITY I <br /> OWNER NAME OWNER PHONE 59-7,- <br /> CONTRACTOR CONT. PHONE <br /> FIRE PERMIT <br /> trl(3(4 <br /> Fo <br /> REMOVAL (,4V CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOPe-I DATE 4'1(21G'7 TANK 39 / ) I- _ <br /> R RINSED (Y6) METHOD RINSE AMOUNT <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E IMANIFEST OR OTHER <br /> V VAPORS PURGED M=OD <br /> AMOUNT USED >f LIT-' <br /> A <br /> P READING AT REMOVAL L.E.L. 02: <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL (4 E , FIBERGLASS, OTHER) <br /> li2 <br /> N TANK CONDITION (GOOD, gHOLES) <br /> S <br /> .z <br /> P TM= (��, FIBERGLASS, OTHER)7 EMT <br /> PIPE CONDITION (GOOD, PDO HOLES) <br /> DEPTH SOIL TYPE JOBSERVATION SAMPLE <br /> A <br /> S EXCAVATION SIZE r 5t- X-,3z, X=YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE JOBSERVATION SAMPLE <br /> P P <br /> L I <br /> I P <br /> G <br /> TRENCH Dimm4slam X x YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> 0 <br /> LLOTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: Gov <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />