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PUBLIC HEAcrH SERVICES-ENVIRONMENTAL HLALTH DIVISION <br /> SITE NAME 7 DRESS 3776 R c 3t CITY 7-M <br /> OWNER NAME cwVpo-X f OWNER PHONE <br /> CONTRACTOR CONT. PHONE <br /> IRE PERMIT # <br /> REMOVAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR DATE \ �'_J ' `( l� TANK # 39 <br /> EER NS Y ) METHOD RINSE AMOUNT <br /> I <br /> N NSATE DISPOSAL SITE ++ <br /> S <br /> MANIFEST Al OR OTHER <br /> V VAPORS PURGED Y N) THOD 1 CX AMOUNT IISED <br /> A <br /> P READING AT REMOVAL L.E.L. : 02:- <br /> 0 <br /> 2:— _- <br /> R COMMENTS !. <br /> C TANK MATERIAL (STEEL,(: IBERGLASS, `HER) r D (j 5-00 U G S <br /> ° TaPaJK cvaas <br /> N TANK CONDITION (GOOD, POOR, HOLE ) tet' <br /> S <br /> T PIPE MATERIAL (STEEL, flBERGLAS OTHER) FEET N �� <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> T <br /> A IV EDT4�� <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 1 HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: w 0. S yer-K I /e, <br /> LABORATORY: SAMPLERS NAME: je_4�Vth64h ) sk <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />