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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME � ,� G��`"Y ADDRESS CITY <br /> OWNER NAME OWNER PHONE (Zai) G�4 - Z 4 <br /> CONTRACTOR CONT.CONT. PHONE # <br /> FIRE PERMIT ?? , <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR y'`- DATE �olig �s > TANK # 39 <br /> R RINSED (YM METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> IFEST � �, . OR OTHER <br /> i_ <br /> V VAPORS PURGED (Y/N) METHOD AMOUNT USED �D <br /> A <br /> P READING AT REMOVAL L.E.L. : jd 02: c� <br /> O <br /> R COMMENTS <br /> C TANK MATERIAL TEEL;yFIBERGLASS, _OTHER) <br /> O 1 __ <br /> N TANK CONDITION (GOOD Pd R, HOLES) <br /> T PIPE MATERIAL STEEL, FIBERGLASS, OTHER) # FEET <br /> PIPE CONDITION (GOODrfOOR.; HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE , <br /> A <br /> N <br /> K <br /> S EXCAVATION SIZE 6�g J X 9' X - ?f 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 /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br /> v% �` �I I/✓� /�L- ���`+'�7 �`7 y/1. +-"�� �%'�i.�G�f���-✓ <br />