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PUBLIC HEALT'O SraVICES-ENV'�RONM=AL HEAbtd DIVISION <br /> -T- <br /> SITE NAMED,40�",!�p `ADDRESS G`9�/���y1- CITY <br /> OWNER NAME <br /> IOWN`ER PHONE <br /> CONTRACTOR 5 CONT. PHONE <br /> FIRE PERMIT T4-A— <br /> f, OVAL _ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK r 39 <br /> R RINSED (Y/N) I _b=- OD I RINSE AMOUNT <br /> '1 <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) (METHOD AMOUNT 'USED <br /> A <br /> P READING AT REMOVAL L.E.L. : 102: <br /> 0 <br /> R COMMENTS 70 <br /> C MATERIAL F rB]��, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD, POOR, HOLES) <br /> S <br /> T PIPE MATERIAL (� � OTHER) + r FEET 27�! <br /> PIPE CONDITION (GOOD, <29;p, HOLES) <br /> DEPTH ( SOIL TYPE OBSEtVAT:ON ( SAMPLE <br /> A <br /> N I I <br /> K i I i <br /> I I <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH ISOIL TYPE (OBSERVATION SAMPLE <br /> P P <br /> L I �5 I I -'df <br /> T P o�C I <br /> N E <br /> G I I <br /> TRENCH DIMENSION ^27$ X X YDS OF SOIL- <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> fi <br /> 2 r HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: � , Jy I SAMPLERS NAME:LL <br /> CLOSURE IN PLACE I 3%11XTORE: ( VOLUME: f <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />