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RLLSTAR PETROLEUM EQUIP 209 2770106 P. 04
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<br /> UNDRRGROUND MWAGK TANK DISrOSMON TRACKDFG RRCORD
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<br /> fist WN l -Public Health Servim Traeldsg Skeet will atmmpany Back took dfised with Its site Identification somber.
<br /> The Tracking Skeet It to be Morsed to Public Health Selvicet wlthhs 30 dtn of acceptance of Ike tank by the dhpmd or
<br /> recycling testy. The pJm1rY holder is responsible Por emdrhtg that this Fera(Is eompleiad and rawne&
<br /> FACII 17Y NAME: 44d,1(Son�Io �! ,�q�lnfi/A /F1e Rai tt,.jav r1;,.> .�✓
<br /> FACHL TT ADDREW. 3 orJ JW .bid Nm7/g lc�A-,ate �Ip'N
<br /> TANK W 039.1. Task Desariptbn:
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<br /> SWn0N a-To be tilled Got r�tno!a coou r: e
<br /> Task Removal Costrsdor ��QSi _`10 rri ((!c 14 Eyif"f �C -
<br /> Addreas Zo/ /l7ci,;AWl(4 Dr i u� cuy r/r1 a[�erG. 71p: �3b3 7
<br /> Phone IF: Z1) ) 47J%(ISS3 Dale Tank Removed:
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<br /> MWI110114 3-To be filled Get by contraclorodecW40116atioltb
<br /> Tank Demstomhtatlon Contmotor: L e `s a! Y_rlUclhrttY?iil�a� LrtC
<br /> Address: -;7,VI ��Gin ✓ �ft✓� City �lGldt'lti7Jp: E���
<br /> Phom#:c iso 1) &T51 Gi356
<br /> Avtbotiaed talmmotnive of contractor oerti"S through sigesture below that the task las been decontamis'ated in an
<br /> approval massed a tetpdfai by Cal BPA.
<br /> Sip ipty;
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<br /> SWn0N 4-To be olgaed and dated by an a dbertsed r oeogstadve of the treatment,atomge,or disposal facility
<br /> accepft task mtabr Piphill
<br /> pgc my borne: iT >,Q2Aer al P.fy C D
<br /> Addrrs< e-,-1iufLC i&a Slode /SkoL sty 6eSelo zip: 93 7�
<br /> phone*: ' n9) ;13-1-6677
<br /> Date Twit ReeeJved:
<br /> Slgnsium True:
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