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mvm Aaw unrw uuN 6 HIS I UHY FORM xa ; <br /> DATE / ' % Mid Valley.Inventory Number, r <br /> RECEIVED FROM: <br /> OWNER W'AAIA Ipfrls-i--OpI I r r r 1 1 1 1 SHIPPER <br /> ADDRESS r r r r r r r r r r ADDRESS r l r r r r rrrrr r r r r r r r r r r r <br /> CITY STATE ZIP r r r r r r r r r r CITY STATE ZIP r r i r r r r r rrr r <br /> PHONE r r r r r_ r r r PHONE r r _ <br /> CONTACT r r r r r i r r r r r r r r r r r r r r i r r r i r r r r CONTACT <br /> TANK INFORMATION <br /> MOVED FROM r r r r OV're,r 1 1 1 1 1 1 1 1 1 1 1 1 1 CLEANED BY r r CUVr r r r r r r r r i r r r r i r r i i i <br /> CITY STATE r i r r r r r r r r ADDRESS <br /> PRIOR USE IYJ R r r r r r r r r r r r CITY STATE ZIP r r r <br /> SIZE I& I!> PHONE <br /> UL # r is.1 .4r i r r i i i r i r r r r CONTACTr r r r r r r r r r r r i t r r i i i r i r rrr r <br /> MANUFACTURER r i i r r r r i i r r r i r r i r i i i r r i r i i r <br /> TANK CONDITION id r ror <br /> CONTAMINATION INFORMATION <br /> (COMPLETE ONLY IF TANK IS CONTAMINATED) <br /> SUBSTANCE(S) i 101k Li r r r r r r i r i r i r r r r r r r REJECTED %B1rPPIt�1nWNF7R <br /> r r r r r i r r r r r 11 11 r r 1 r 1 r r r r r r <br /> UM <br /> (in Gal. ) r r r ACCEPTED B -1f r'l-rq <br /> COMMENTS (0 tional) SIGNATURE <br /> VERIFICATI <br /> VERIFIED BY r r r r r r r r r r r r r r r i r r i i rrrr rrr r <br /> SIGNATURE n <br /> JAN <br /> ENFIERMI- CAL <br /> LTH <br />