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V <br /> PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ffoN7l DRESS CITY <br /> OWNER NAME a D/Il r . OWNER PHONE # <br /> CONTRACTOR C `+ C � ( ; S CONT . PHONE # <br /> FIRE PERMIT RnGY <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE TANK # 39 D <br /> R RINSED eN ) METHOD n RINSE AM UNT <br /> I <br /> N RINSATE DISPOSAL SITE /IAU4,t5l Lay Lnji/ r Ro <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED , Y /N ) THOD AMOUNT USED <br /> A <br /> P READING AT REMOVAL L . E . L . : 02 : , -7 <br /> O <br /> R COMMENTS <br /> C TANK MATERI ( STE , , FIBERGLASS , OTHER ) <br /> O <br /> N TANK CONDITION ( GOOD , POOR , HOLES ) <br /> S <br /> T PIPE MATERIAL ( STEEL , FIBERGLASS , OTHER) '#` FEET <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T <br /> A r - <br /> N <br /> K <br /> S EXCAVATION SIZE X X 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 . : II 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 />