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PUBLIC HE& SERVICES—ENVIRONMENTAL 4kLTH DIVISION <br />SITE NAME <br />ADDRESS <br />CITY <br />OWNER NAME <br />OWNER PHONE <br />, <br />CONTRACTOR <br />CONT. PHONE <br /># <br />FIRE PERMIT , <br />REMOVAL CLOSURE IN PLACE <br />TEMPORARY CLOSURE <br />INSPECTOR <br />DATE 2 <br />24. TANK39 <br />R <br />RINSED((Y/ ) METHOD 2i <br />RINSE AMOUNT <br />noI <br />E 0 <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST <br />OR <br />OTHER <br />V <br />VAPORS PURGED((Y N) <br />METHOD <br />AMOUNT USED &, <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: <br />02: <br />O <br />R <br />C <br />COMMENT <br />TANK MATER TEFL <br />FIBERGLASS, <br />OTHER) <br />O <br />N <br />TANK CONDITION (GOOD(POOR, <br />HOLES) <br />S <br />T <br />PIPE MATERIAL fE <br />FIBERGLASS, <br />OTHER) <br />, FEET <br />PIPE CONDITION (GOOD, <br />00R, HOLES) <br />S <br />T <br />A <br />N <br />K <br />DEPTH SOILT <br />I <br />OBSERVATION <br />SAMPLE , <br />w <br />toff <br />Iee se <br />EXCAVATION SIZE X X <br />YDS OF SOIL <br />A <br />M <br />P <br />L <br />I <br />N <br />G <br />P <br />I <br />P <br />E <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE <br />TRENCH DIMENSION X <br />X YDS OF SOIL <br />IJLOTHER <br />x <br />2 <br />0 <br />DEPTH TO G.W.: FT. <br />SAMPLING METHOD <br />if HOURS SINCE DEWATERING: <br />SAMPLE: <br />LABORATORY: <br />SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />