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PUBLIC HE& SERVICES-ENVIRONMENTAL ATH DIVISION <br />SITE NAME "(-)ADDRESS <br />ADDRESS <br />u i �, j G�x'w{ CITY S <br />OWNER NAME �S � /',It OWNER PHONE �# 227 5 _ 7 � - 71 .SIO - 6 S 7- S-yz <br />CONTRACTOR CONT. PHONE # <br />FIRE PERMIT <br />REMOVAL V" CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR DATE TANK 39 % Z_ 6 <br />R RINSED ON) METHOD -�-� RINSE AMOUNT 30 <br />I p <br />N RINSATE DISPOSAL SITE (J , J;.�o w •�t <br />S <br />E MANIFEST OR OTHER <br />V VAPORS PURGED /N) METHOD , AMOUNT USEDL4 �a <br />A <br />P READING AT REMOVALL.E.L.: - ci 02: <br />O <br />R COMMENTS CD]L <br />C TANK MATERIAL (STEEL,ZBERG S, OTHER) <br />O <br />N TANK CONDITION (GOOD, P , HOLES) <br />S <br />T �_l <br />PIPE T (ST , �.ERG S, O )-z FEET <br />PIPE CONDITION (GOOD 00 HOLES) <br />DEPTH SOIL TYPE OBSERVATION SAMPLE Fz <br />T , <br />A `3 <br />-Z <br />N <br />K <br />S EXCAVATION SIZE X X YDS OF SOIL <br />A <br />M DEPTH SOIL TYPE OBSERVATION SAMPLE <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 />H <br />2 HOURS SINCE DEWATERING: <br />0 <br />LLOTHER SAMPLE: <br />LABORATORY: SAMPLERS NAME: <br />CLOSURE IN PLACE MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />