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PUBLIC HEAM'H SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />SITE NAME % (� �j�(,4 L� <br />elr <br />DRESS`S, <br />CITY <br />C� <br />OWNER NAME /�� <br />OWNER PHONE # <br />CONTRACTOR )'1 5 (' Cm,l <br />CONT. PHONE # <br />_ CLOSURE IN PLACE TEMPORARY Ci.OSURE <br />INSPECTOR <br />DATE C(,] �% TANK if 39 <br />R <br />I <br />RINSED (Y/N) METHOD <br />RINSE <br />AMOUNT <br />N <br />RINSATE DISPOSAL SITE <br />S <br />E <br />MANIFEST <br />OR OTHER <br />V <br />VAPORS PURGED (Y/N) <br />METHOD AMOUNT <br />USED <br />A <br />P <br />READING AT REMOV <br />L.,E.L 02: <br />t'L <br />0 <br />R <br />COMMENTS <br />144 <br />_. q <br />C <br />0 <br />TANK MAT IAL (STEEL, <br />FIBERGLASS, OTHER) <br />N <br />S <br />TANK #NDITION (GOOD, <br />POOR, HOLES) <br />T <br />PTPOfMATERIAL (STEEL, <br />FIBERGLASS, OTHER) FEET <br />DEPTH SOIL TYPE <br />OBSERVATION <br />SAMPLE # <br />T <br />A <br />N <br />, I <br />'17 a c. <br />' <br />K <br />XCAVATION SIZE �tX � X %.Lj <br />YDS OF SOIL <br />`� dS a <br />S <br />A <br />M <br />DEPTH SOIL TYPE <br />OBSERZATIML <br />SAMPLE # <br />P <br />P <br />L <br />I <br />I <br />P <br />E <br />N <br />G <br />TRENCH DIMENSION <br />X X <br />YDS OF SOIL <br />DEPTH TO G.W.: <br />FT. <br />SAMPLING METHOD <br />H <br />2 <br />HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: <br />LABORATORY: j p <br />/19PQ C �L�, <br />SAMPLERS NAME: <br />CLOSURE IN PLACE <br />MIXTURE: <br />VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />