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PUBLIC HEAL VICES-ENVIRONMENTAL DIVISION <br />SITE NAME G L® DRESS C'Z CITY <br />OWNER NAME 5 ® I OWNER PHONE <br />CONTRACTOR (CONT. PHONE <br />v , <br />FIRE PERMIT <br />REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br />INSPECTOR 'G' DATE TANK 3 9 1/ <br />R RINSED ) METHOD c RINSE AMOUNT <br />I <br />N RINSATE DISPOSAL SITE <br />S <br />E MANIFESTOR OTHER <br />V VAPORS PURGID N) METHOD �, AMOUNT USED <br />A <br />P READING AT REMOVAL I L. E. L. 7 <br />02: <br />0 <br />R COMMENTS <br />C TANK MATERIAL .� FIBERGLASS, OTHER) <br />O <br />N TANK CONDITION (GOOD, PO , HOLES) <br />S <br />T PIPE MATERIAL (STEEL, BERG S, )FEET <br />PIPE CONDITION (GOOD , OLES) <br />DEPTH SOIL TYPE OBSERVATION (SAMPLE <br />T <br />A � -� i � <br />N <br />K <br />S EXCAVATION SIZE X X YDS OF SOIL �. <br />A F <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 i� X H f�YDS OF SOIL <br />DEPTH TO G.W.: FT. SAMPLING METHOD <br />H <br />2 HOURS SINCE DEWATERING: <br />0 <br />OTHER SAMPLE: 614) 3cr51--y-1 <br />LL LABORATORY: j Ts-AMP NAME: f f" <br />Ae <br />CLOSURE IN PLACE , MIXTURE: VOLUME: <br />EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />ow <br />