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GE oe4 <br /> X71;0!/2f�Ft? E18: 1 ;l ltd:,.<j `,1 f- -:; <br /> 1230/02 MON 18: 37 FAX . tPJuub <br /> SAN .tt,AQ1II N t W)N IN' I'lfit I'" nVA(,TII NI,Itvrr I�-' <br /> Ic.NVI)4()Nh1I,:NTAI, IIT;�[;1'(1 I►IVISI(1N /� <br /> 11N1)1 I(GIMIIND 511,0114A(:b: 'I'nNK t)ISI'OSI'('It)N "t'KAC'KING KF:('ctklt �� _/ <br /> 1rTTTlf ff T/lean aaa�n a'.IF��a as of TaF FFFTfa+11�a..�a.+al..�f{+f•i YYiF/kF/FFF•kt4t�4•A ri t4kr{♦{F{iki l.iF+TT/M! <br /> CI;CTION 1 hubl!c: liraltli .Sctvlccs I,nvn'onlncnl tl I lc,tlllt L?i�lsiun 'tank fracl nig Shea shall accompany each lank uffixcd with <br /> itr. site Idcwification mother The Tank Trackillp Slttca k to be retumcd to PuUlit' lieahh Scrvites Cnvirgnmenlal Healrh Diviclon <br /> WItliln 30 rlltys or acccpuutcc of'dtr tank 0) tile disposal ut rrcyrling facility Tltt• pct-mN I►oldcr iR rmpnnsihlc ror ctLtiuring ilia, <br /> this form Is complc(ed and rrtumcd. <br /> FACILITY <br /> FACILITY ADDRESS: <br /> TANK iD x'39- TANK SIZE:fl�fL pp EVIOCIS TANK CONTENTS: L/„t Z� <br /> iFfTF•wtrMr,lkr•Wi.6w.6 tkttkkR:Wk1(HNWW•tkkKt KwWwwk MRrlk Rt rwMM�tt�ttRTkRt'Rttn'4i4•Rk/Mlft/ttR k•Jkk tMMWwR,MpMM.4F♦Mk4#Fk <br /> SECTION 2 -To be filled out <br /> /by tank removal eontrr2ctor: <br /> Tank Removal Contractor: <br /> Addre15. /I130 !2 CityZip: <br /> Phone a; (wv '?y Oc q- Date Tats:Removed: -- <br /> ■kkk•1Fikw*4*klktWNw/•t k cwa WHlff/t f w t t w w w v w w k•w•t/Wksrtt/akk#ktk4# iM##lVMtt+#t#ka*Mt•k.lkkkikkk.*kA.kkK+A•#kFkR <br /> SECTION 3-To be filled out by contractor"deco�nct-aminatlloogptaabk,":: <br /> Tani, Deeonlasnination Contractor:J� <br /> Address: Q�� 214– / City: Zip: 40_ T <br /> Phone <br /> Authorized representative of contractor certifying through sifinatt,re below that the Ulnk has en eco n ted in an 3pptroveA <br /> mariner as rcquircd by Cal EPA. <br /> Name `�DEf� DA+srt� —Title: -/ �E��a� _Signature: Date <br /> ♦rki;'/•;KY/4ki/r RkkA/tTr�%k{.{:/%'t/f'R'kCk/t/t rr rr Mw ri#•%'#kkk//NRrHtkRR�rr/r/wrr•r{cttt RwYR/tRf TkRl:##'itY./kK}.kt•k <br /> SECTION d -To be signed znd dated by an authurizcd rcprescntat.ivc of the treatment, storege, or disposal leteility <br /> acctpting tank 2 <br /> nd/or pipipg. <br /> i Facility Name: <br /> Addre;s: ,2 City: �i`! Zip: <br /> O f� <br /> ± Datc Tank Received:__ <br /> nature: <br /> `:•3: .;j.?�'M,iRrk/rsrr+R+R+trrfikrt*k tFe+M•%�wvvs../�r�kk*•sxr'frrtr.rr rrr.Rytt/y,�,{rw,Yr44ri%i•i"ktstrr;�R rT•.r�►rF•kwil ii ikF v.I>• <br /> 'E)-1 .3 (116Pjv2 10 <br /> (Rcviscd M!) <br /> t ' <br />