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7-25-1996 d:27PM FROM P. 6 <br /> `7 <br /> VNDERGROIIND STORAGE TANK DfSp=nON TRACENG RECORD <br /> ...........•..........,.•........•...•.•..•...........1............................................•.•.... <br /> SECTION 1 - public Health Services Tncloag Sheet crM acoompa y each tank IMud with its site identification nnmpc_ <br /> The Inciting Sheet is to be tetntoed to Public Health Saviors within 7e dR of accepaace of the tank by the tlitpossl of <br /> g f4CLlity. The paaud holder is ttsponstbic fW=:bring that zbb halm is completed sad cttluned- <br /> ©FACa=NAhfE <br /> &ACiLTIY ADDRESSZ� <br /> ®TANK ID•39- 2 3-7 7_ Tank Dacri <br /> ........................................................................................................... <br /> SECTION Z-To be filled by tank removal conaaaor. <br /> Tank Removal Con f--t-c mow- -rJ t <br /> Address JOIIo Wcsi- k�t�IQw� t N _`Gi l Ori _W][JL!1-9 -"0 <br /> 9 Phone N: 2( 6q 149 F^ 361 ' Slo 3 Date Tank Rewe& <br /> ......................................•................................................................... <br /> SECTION 3-TO be filled om by 'demutaminating(work': <br /> Tank Decontamination C0UVS(Vr.[{j F(ZIG tG���15 CI V KCar)ww L�} L <br /> ®Address: L..SS � 5I -� <br /> /Authorized repfesedtativc Of couttattgr certifying through signature below that the tank has been decouta==ed W an <br /> approved man=as required by Cori EPA. <br /> Signature: Male- <br /> ...#.............*01.........I......*.............SO*......to....0....0.*....... .................. <br /> itle:...........................................................•........................•...•.................. <br /> SECTION. -To r>e ed�and dat«f by an nud ized cepeeseuative of the treatn=r,stotage,or dispocxst tacihty <br /> �Ptmi P1Pm& <br /> Addras: 2Se POLV-Y- city:_ Akmow.» zip: 94$� I <br /> hone x: t Slfl l Z3S- 1393 <br /> &te Tanic Received: <br /> Sigvarure• TTtic: <br /> ...............•..••...............................•.................................................... <br /> EM 23 ec9 (Revised 7-10-92) vR0. 10 <br />