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PUBLIC H 'E SERVICES-ztgv=ONMENMU .LTH DIVISION <br /> 31 <br /> SITE NAY ADDRESS,� �� a CITY S e <br /> OW-N—:-R NAME .rZfic L �C r OWNER PHONE r 3 � <br /> CONTRACTOR 'D1'C� �� CONT_ PHONE <br /> ^IRE. PER= <br /> CLOSURE IN PLACE TMEPOPARY CLOSUP—E <br /> SPECTOR r DATE TAATKT 39'I li <br /> R RINSED (TN) METHOD IZ, k :F RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S 'P I <br /> E MAN Y'SST OR OT= <br /> V VAPORS PGRGr-'D (� N) M T&0D r1N!oIIN'I' USED <br /> P READ ING A-T REMOVAL L.E.L. ! C)% <br /> 02 <br /> O '! G8 <br /> R COMMITS 1 <br /> Jl C ' TANK PIATMTAA! STEL., FIBERGLASS, OTS- ) <br /> a <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S , <br /> T ?I?E IATE2-ar, STEL rI3E„RG-LASS, OTEER) <br /> PIPE CONDI'T'ION (GOOD POOR, HOLES) b y`C <br /> DEPTH SOIL TYPE' OBSr".ZVATION s <br /> T <br /> N I I �� rTI <br /> S :XCAVATION SIZE S X YDS OF Sam, <br /> A <br /> M DEPTH SOIL TYKE JOBSLZ <br /> ERVATION ,' SAMEr <br /> I a P <br /> L I <br /> t u h I I <br /> v I I u <br /> G <br /> T=CH DzMENSION X X II I YDS OF SOIL <br /> DEPTH TO G.W_ : FI. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERNG: I'I <br /> 0 <br /> OT= SAMPLE: <br /> LABORATORY: C- SAMPLE-RS N 42. <br /> CLCSUi t"'N PLACE �: V <br /> oLDlM: <br /> ER 23-0043 (R-vV 2/23/94) PROVIDE SITE MAP <br />