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PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />1ADDRESS <br />OWNER PHONE <br />CONTRACTOR <br />CONT. PHONE <br />C -!V-5-777 <br />REMOVAL )f CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE efj,wJ-j�gnlzmi <br />;:RINSE CVN) M <br />RINSATE DISPOSAL SITE <br />MANIFEST OR 0 <br />• <br />VA PORS P URGED CVN) <br />• <br />11 -1 r III <br />01 <br />:TANK MATERIAL (S#ELIBERGLASS, OTHER) <br />• <br />iTANK CONDITION (GOOD, <br />LES) <br />'PIPE MATERIAL (STEEL, <br />FIBERGLA SS,OTH <br />PIPE CONDITION (GOOD, <br />POOR, HOLES) <br />OBSERVATION <br />EXCAVATION SIZE -�S75_ X`17" X`�3'_ <br />DS OF SOIL <br />iOBSER ATION <br />TRENCH DIMENSION <br />x x �IYDS OF SOIL <br />• <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />I HOURS SINCE DEWATERING: <br />CLOSURE IN PT.J�CE <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />V.- <br />