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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ��r,C� P+ DRESS _4`775 rlglg-C �/vCITY <br /> OWNER NAME OWNER PHONE # <br /> CONTRACTOR CONT. PHONE # <br /> FIRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE jj-1� 17 TANK # 39 Y L Sr 2_ <br /> R RINSED (Y N) METHOD RINSE AMOUNT <br /> I <br /> N RINSATE DISPOSAL SITE t::-&4 G K-rCJ <br /> S <br /> E MANIFEST # OR OTHER <br /> VVAPORS PURGED (Y/N) THOD AMOUNT USED <br /> A <br /> P EADING AT REMOVAL L.E.L. : 02 : <br /> 0 <br /> RCOMMENTS <br /> CTANK MATERIAL (STEEL, BERGLASS, OTHER) N6K/&e-- <br /> O _ <br /> NTANK CONDITION (GOOD, gOOR6�OLES `u bs <br /> S <br /> T IPE MATERIAL (STEEL,(2IBERGLMS j OTHER) # FEET <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T V bN <br /> A Alla <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. : FT. SAMPLING METHOD <br /> H <br /> 2 # HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> IF—CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />