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PUBLIC HEALT$'SERVICES-ENVIRONMENTAL HEAL'H DIVISION <br /> SITE NAMEV DRESS, ,31 �' �A�i' �L! c CITY S foUf� <br /> OWNER NAMEb IOWNER PHONE <br /> CONTRACTOR-rho r e oil I CONT. PHONE <br /> FIRE PERMIT C16_ / .7,5 <br /> REMOVAL_ CLOSURE IN PLACE p TEMPORARY CLOSURE <br /> INSPECTOR B ifs DATE (0'7' / Ln TANK } 3903 <br /> q' <br /> R RINSED (Y/© jj METHOD RINSE AMOUNT <br /> Z <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E MANIFEST # OR OTHER <br /> V VAPORS PURGED (Y/N) (METHOD AMOUNT USED <br /> A r, <br /> P READING AT REMOVAL I L.E.L. : 0 0 102 : <br /> O <br /> R COMMENTS <br /> C TANK MAT (STEEL;, FIBERGLASS, OTHER "oldT4totf <br /> 0 <br /> N TANK CONDITION (GOOD, POOR HHO ) ✓ L� <br /> S <br /> T PIPE MATERIAL (STEEL) FIBERGLASS, OTHER) 0 FEET <br /> PIPE CONDITIONGOODS POOR, HOLES) <br /> DEPTH ( SOIL TYPE OBSERVATION ( SAMPLE <br /> T <br /> A <br /> N <br /> K > <br /> K <br /> S EXCAVATION SIZE _ X X YDS OF SOIL <br /> A <br /> M DEPTH ( SOIL TYPE OBSERVATION SAMPLE <br /> P P c, <br /> L I <br /> I P M)crey <br /> h - <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. ( SAMPLING Y=OD <br /> fi <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: e6 SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: VOLUME: <br /> EH 23-0043 (R-77 2/23/94) PROVIDE SITE MAP <br />