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PUBLIC HA SERVICES—ENVIRONMENTAL WTH DIVISI <br />SITE NAMEu i � S ! ZO <br />ADDRESS �? 3 Z/ J <br />CITY .S <br />OWNER NAME s <br />OWNER PHONE <br />CONTRACTOR .s ' <br />CONT . PHONE # �! 6 _ 6 _s3 / hr/ <br />wc. <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR <br />DATE If. TANK f 39 / Z 6 <br />R <br />RINSED (01N) METHOD <br />RINSE AMOUNT <br />N <br />RINSATE DISPOSAL SITE Sc z ,C1M <br />S <br />E <br />MANIFEST # - <br />OR OTHER <br />V <br />VAPORS PURGED Y ) <br />METHOD kjU AMOUNT USED <br />A <br />P <br />0 <br />READING AT REMOVAL <br />L.E.L.: %-� 02: <br />R IICO14MENTS <br />C <br />TANK MATERIAL (STEEL, <br />BER SS, OTHER) <br />O <br />N <br />TANK CONDITION (GOOD, <br />60pi, HOLES) <br />S <br />T <br />PIPE T IAL (STEEL, <br />B �G, O ) T <br />PIPE CONDITION (GOOD, <br />O HOLES) <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE` <br />T <br />A <br />.S' I <br />� <br />dow <br />N <br />K <br />S <br />EXCAVATION SIZE 'X & X / <br />YDS OF SOIL o Cs <br />A <br />M <br />DEPTH SOIL TYPE <br />OBSERVATION SAMPLE <br />P <br />L <br />P <br />I <br />3,dEc <br />, 91 <br />& <br />zi ° z - <br />I <br />P <br />N <br />21 1 <br />no jo <br />G <br />n <br />TRENCH DIMENSION <br />X X YDS OF SOIL <br />TO G.W.: <br />--jDEPTH <br />FT. SAMPLING METHOD <br />H <br />2 <br />, HOURS SINCE DEWATERING: <br />0 <br />SAMPLE: <br />LljOTHER <br />LABORATORY :_Sh,,j <br />I SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: -7 <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />