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PUBLIC HEOH SERVICES -ENVIRONMENTAL ATH DIVISION <br />SITE NAMEuiIL s Zp <br />ADDRESS �� Z(� j Ge�w �f <br />CITY S <br />OWNER NAME K-Srtokd, /,,c <br />I OWNER PHONE7- <br />CONTRACTOR / �S �t <br />CONT. PHONE <br />FIRE PERMIT b <br />C.O S �] <br />REMOVAL 1% CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE TANK P 39 /2-6/ 2 <br />R RINSED N) METHOD RINSE AMOUNT <br />Y4 <br />I <br />N <br />RINSATE DISPOSAL SITE ✓, <br />S <br />E <br />11MANIFEST , OR OTHER <br />V <br />VAPORS PURGED N) METHOD i1 -e_- AMOUNT USED !tel <br />A <br />P <br />READING AT REMOVALL.E.L.: 02: cd <br />0 <br />R <br />ICOMMENTS llc <br />C <br />TANK MATERIAL (STEEL,,BERGL S, OTHER) <br />0 <br />N <br />TANK CONDITION (GOOD, OOR HOLES) <br />S <br />T <br />PIPE MATERIAL (STEEL,jj�&�G S, OTHER', <br />F <br />PIPE CONDITION (GOOD, P R HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE <br />T <br />A <br />N <br />o nddc -► <br />► -Z <br />I <br />K <br />t <br />S <br />EXCAVATION SIZE X X <br />YDS OF SOIL, <br />A <br />M <br />DEPTH SOIL TYPE OBSERVATION <br />SAMPLE , <br />P <br />L <br />I <br />N <br />P <br />I <br />P <br />E <br />__.altc <br />i <br />spZ <br />t A -, '3 <br />TRENCH DIMENSION X X <br />YDS OF SOIL <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />H <br />2 <br />J4 HOURS SINCE DEWATERING: <br />0 <br />SAMPLE: <br />LLOTHER <br />LABORATORY:. SAMPLERS NAME: <br />ECLOSURE-IN PLACE XTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />