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PUBLIC HEALT�[wSERVICES-ENVLRONM=AL HEAt'lwd DIVISION <br /> SITE NAiK.EGJ ��y� `ADDRESS G�9�/��Et�- CITY <br /> OWNER NAME I OWNER PHONE <br /> CONTRACTOR s ICONT. PHONE <br /> FIRE PERMIT TIJI-i4- <br /> OVAL _ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK 39 <br /> R RINSED (Y/N) I b=- OD I RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> LiJIMANIFEST OR OTHER <br /> V VAPORS PURGED (Y/N) (METHOD (AMOUNT 'USED <br /> A <br /> PREADING AT REMOVAL I L.E.L. : 102: <br /> O <br /> R COrn�ri*rS 7- <br /> C <br /> C MATERI.a.L F'3��-;-T.A SS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (ST,� OTHER) I T FEET Z- <br /> 7-'g5;-PIPE CONDITION (GOOD, <180p, HOLES) <br /> DEPTH ISOIL TYPE ( OBSERVATION I SAMPLE <br /> Ir <br /> A <br /> N <br /> K I I ! <br /> I I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ( SOIL TYPE (OBSERVATION SAMPLE <br /> D <br /> L T �- I Ii <br /> -it <br /> I P <br /> N <br /> I I <br /> G <br /> TRENCH DIMENSION ^?i7$� X ^/_� X I YDS OF SOIL- <br /> DEPTH TO G.W. : FT. ( SAMPLING METHOD <br /> H <br /> 2 rx HOURS SINCE DEWATERING: <br /> 0 <br /> LLOTHER SAMPLE: <br /> LABORATORY: � y l SAM.PLr'"'f. S NAME: <br /> CLOSURE IN PLACE I MIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />