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PUBLIC HFAjTH S-r.R710ES-EINVLRCNbMNTAL HEALTH DIVISION <br /> SITE NAME Z I ADDRESS _( 7D I J I CITY(y) <br /> OWNER NAME I OW74F.R PHONE <br /> G 7 <br /> CONTRACTOR �" � CON'^. PHONE <br /> FIRE PERM-IT T I <br /> R1z^4OVAL CLCSL'RS --' T PLAN TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 <br /> R RINSED / I MEPHOD RT-NSE AMOUNT <br /> I <br /> N R-'NSATE DISPOSAL SITE �f/lll/ �— <br /> I <br /> SOR OTHER <br /> E ,SANIFEST i <br /> V VAPORS PLRGED (' /N) I IN=-QOD I DUMC Y-r USED <br /> A 02: <br /> P READING AT R_�SOVAL i L.E.L. : <br /> 0 <br /> R I COmirmiTS <br /> I <br /> C TA�`TK M-,Tt-RT3L ( . :T_3c. S, OTHM) I <br /> 0 <br /> N TANK CONDITION (GOCD, O , HOLES) <br /> S <br /> T PIPE' ?SAm-r-M _3L (ST=, =g ZRGI SS, OTS) <br /> i <br /> PIPE CONDI=ION (GOOD, POOR, HOLES) <br /> DE'TH SOL- TYPE I OBSERVATION ( S ' ' T <br /> T <br /> A <br /> / Y <br /> Z <br /> S E,YCAVA.TION SIZE Y S YDS OF SOil <br /> `AOBSERVATIONI SAMPM2 r <br /> M I DEPTH ISO= T'IPE OBSERVATION <br /> P I P i <br /> L — <br /> I P I <br /> N E 04I <br /> G SION IYDS OF SOIL <br /> T-,RM"TCr 013 `7 <br /> DEPTH TO G.DT. : FT. I SAL-i METHOD <br /> H <br /> 2 r HOURS SINCE OEWATMRT"4G: <br /> 0 <br /> OT"= SAMPLE: <br /> L2,.BCRSTCRY: 5 � �=: <br /> CLOSi7RE IN PIA= I 1!=ARE: I VOLLZ�;: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />