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PUBLIC HAH SERVICES -ENVIRONMENTAL I&LTH DIVISION <br />SITE NAMEADDRESS i/ CITY , <br />OWNER NAME OWNER PHONE , <br />CONTRACTOR CONT. PHONE # <br />FIRE PERMIT , <br />REMOVAL_ CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR C� V� DATE TANK 39� <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 �Y N) METHOD AMOUNT USED <br />A <br />P READING AT REMOVAL L.E.L.: 02: <br />0 <br />R COMMENTS <br />C TANK MATERIAL TE , FIBERGLASS, OTHER <br />O <br />N TANK CONDITION (GOOD, OOR HOLES) <br />S <br />T PIPE MATERIAL T , FIBERGLASS, OTHER) , FEET <br />PIPE CONDITION (GOOD, �®R HOLES) <br />DEPTH SOIL, TYPE OBSERVATION SAMPLE ,*4 <br />T 5`. NQ ^ 6 <br />N <br />K <br />S EXCAVATION SIZE X X YDS OF SOIL R <br />A <br />M DEPTH SOIL TYPE OBSERVATION SAMPL if <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 />x <br />2 # HOURS SINCE DEWATERING: <br />0 <br />LLOTHER SAMPLE: <br />. LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: I VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />