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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> I \Ac <br /> SITE NAME C e v r o7 DRESS J 7 ?j • TR&C 9 o Lt ICITY <br /> WNER NAME OWNER PHONE } <br /> CONTRACTOR CONT. PHONE } <br /> IRE PERMIT <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR Q� DATE + t-1- 5 TANK a 39 LLL C .�— <br /> RRINSED (Y ) METHOD �ke RINSE AMOUNT <br /> I <br /> N INSATE DISPOSAL SITE CRICKSOW <br /> S <br /> EMANIFEST OR OTHER <br /> VAVAPORS PURGED (Y/ ) IMETHOD c z AMOUNT USED <br /> PREADING AT REMOVAL L.E.L. : 02 : <br /> O <br /> R OM14ENTS <br /> CTANK MATERIAL (STEEL, IBERGLASS, ,,OTHER) J <br /> 0 — <br /> 6� an h%be /aSS <br /> NTANK CONDITION (GOOD P�OO_R,) HOLES) 7A,/Ot /3RElix r <br /> w fe'^ <br /> IBtl6u� <br /> S m <br /> T IPE MATERIAL (STEEL `FERGLASS,, OTH ) #_cFE _ <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE JO <br /> AAe4lg , <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. : ' - , r� FT. SAMPLING METHOD <br /> H <br /> 2 J4 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE I MIXTURE: ( VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />