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PUBLIC H Sr"RVICES—ENVIRONj4ENTAL BWTH DIVISION <br /> SITE % p-t7 ADDRESS G. t`�f/d Gc/ CIT ��k <br /> OWNER XAqyOWNER PHONE ,� �/� i Z GJ"7 /f <br /> f' <br /> CONTRACTOR i CONT. PHONE r /(� 6�7 <br /> FIRE PST <br /> REMOVAL® CLOSURE MT PLACE - TEMPORARY CLOSURE <br /> INSPECTOR y,,,,: r� C.?.? DATE�O —� TANK r 3 9 / -- <br /> R RINSED RINSE AMOUNT . <br /> I <br /> N RINSAATE DISPOSAL Ste° <br /> S <br /> E MANIFEST r OR OTHER <br /> V VAPORS PURGED !,(v/ �) I METHOD / /za� (?MOUNT USED <br /> A <br /> P READING AT REMOVAL I L.E.L. ®„ ( 02: <br /> 0 <br /> R CDMMF���'S <br /> 14166 <br /> C TANK MAT��2IAL (ST�_ , r ERGLASS,`)OTR) <br /> 0 <br /> N TANK CONDITION (GOCD, POOR, HOLES) <br /> S <br /> PIPE Ma,TERS.�L STS FIBERGLASS, OTHER) <br /> LT <br /> : FEET <br /> PIPE CONDITION �(GOCD POOR, HOLES) <br /> DEPTH ( SOIL �"°ti?E I OBSERVATION ( SAMPLE <br /> lT <br /> A <br /> N <br /> R I /thP <br /> S EXCAVATION S zz X X . IYDS OF SOIL <br /> M DEPTH SOIL T4''E OBSERVATION ( SAI P . <br /> P P1 — <br /> IV 1-fy s s i ay e/1- X <br /> A <br /> L I _ <br /> /5 art. •._. f �' ro 6 /f,I <br /> Nw <br /> G <br /> TIRENCH D1",=SION X X 7;ms OF SOIL <br /> DEPTH TO G.A. :� FT. SAMPL.7*TG METHOD <br /> H <br /> 2 HOURS SIN(= DESv-.TER—TNG: <br /> 0 <br /> 0TR SAMPLz: <br /> LABORATORY: C L (SAID . S NAME: �- <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> -:n 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />