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m <br />PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME <br />ADDRESS <br />CITY <br />OWNER NAME <br />OWNER PHONE <br />CONTRACTOR <br />CONT. PHONE <br />FIRE PERMIT # <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE TANK # 39 <br />R RINSED N) METHOD t - L� ( RINSE AMOUNT 2 <br />I <br />N <br />RINSATE DISPOSAL SITE <br />E <br />V <br />MANIFEST LFj 63'Sfl OR OTHER <br />VAPORS PURGED (Y/N) METHOD AMOUNT USED L <br />A <br />P <br />READING AT REMOVAL <br />L.E.L.: �� <br />02: <br />0 <br />R <br />COMMENTS <br />MATERIAL STEEL FIBERGLASS, OTHER) <br />TANK CONDITION (GOOD, OOR HOLES) <br />LNTANK <br />PIPE MATERIAL (STEEL, FIBERGLASS, OTHER) <br /># FEET <br />PIPE CONDITION (GOOD, POOR, HOLES) <br />S <br />A <br />N <br />K <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />G C C? - ( { ( C7 <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 />n <br />DEPTH SOIL TYPE OBSERVATION SAMPLE # <br />VL ,- <br />TRENCH DIMENSION X X YDS OF SOIL <br />H <br />2 <br />0 <br />DEPTH TO G. W.: FT. SAMPLING METHOD <br /># HOURS SINCE DEWATERING: <br />OTHER SAMPLE: 1 <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: <br />-7 <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />