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WELT COAST EQUIP SALES 1 209 S69 9382 P. 01 <br /> 'r♦.iANCED GEUENvIP.UrN.1 209 d67 1118,„f <br /> r <br /> $AN JU.�QU7N COUITY PGJ3LIC HEALTH SERVICES <br /> FKMOM•IENTAI, kMALIII DIVISION <br /> l`JLYJ+GROIJA'D STORAGE TANK DISPOSITION TRAUMIG RL•CUR1) <br /> .....*,Y.................1,.......a.>r..f YYr....»»........ .............f.>}............. <br /> .:.-t:"n�tN'l•'i•'sblie He%lth Se:-:ces Envicunmental Health Division Tads Tracking Sheer shall accoirpany each tank <br /> ;:idcn.`:Ccatiou a rmbcr. 1i a Tack Trnekin3 Sbcrt is to be retnmed to Public Health Strviecs Eavirotutttntal Hcalcn <br /> ;,pr. vittt} 'in Ears of acr_ptaace of the tank by the disposal or recycling facility. The permit holder is resprnntole for <br /> zt ;mt fora is completed aad renamed. <br /> GAG I1 DF+ � _ <br /> ADDRESS'-. <br /> -J . SIZE!_ /. � P�VIOt S TANK CON7Ei�75:_iY19SU/?� �...�__ <br /> ..................... ..r..r...#..r..r.w.44#......rr...,.......#rYYrW........rw... .........:•...._ <br /> - - To he Riled out by tank removal contractor: <br /> ,..,;oval Coacractor: /L/�' �d��._ <br /> WiN 7&7 [ivHG/_ City: 7.1o: <br /> —/doh, - - Date rank Removed: <br /> ...._................a...r............ra........f...wr.wrrr....r..#44a##a>rrrur......irw+rw#r/.o>..>........ <br /> 10.N 3 • To 0a flled out by contractor "decontaminating tank": <br /> 7c_,r v...unarioc Contractor. <br /> r^pre:eatarive of cautractor cenifyin;through signaaue below that the tack has been decontaminated is au aopto-+t <br /> Cd EPA. <br /> -:,:.."__i t?_�e^'C-' �`/1-�'r'r✓iitlet O�L.'�}'_Sigaa[ute: �. _Datt___ .. ._._-.. <br /> aY.>../>......•....••./.r......r......1##/M.Y>r...YYfkfY......YIIMRRIrirf...w.r•....... <br /> r.... <br /> :t To be sigaed and dated by =authorized represtntative of the treatment. storage. or deposal facW[.v <br /> accepting tads and/or piping. <br /> /Da Ctry. 1�210G4i<_Lip: <br /> ff ?:Ile �jQ��(� . —_Stg']aMr -Dale <br /> .. .....__..>-..................................w..........•r....r...r.o......rrr...... <br /> .r.r..r...,....... <br /> ,R-•.ut19::I.9o, Page 10 <br />