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Ejl!N7, 2fifi=l I'tF J ilt�� 11--.18 ADA•HS SERV TCF`, D11— <br /> ;112 X <br /> • ~�E <br /> 12/3001; 1fi: 3B FAX O• 1-1006 <br /> 5Ar4 .1OA011IN' COUNTY 1'0111.11( 111,A1.rtl <br /> I-:NVIR()NMFNTAl. 11LAIA-11 DI VI H)N <br /> ltNl>Itltt ltlr(IND S7'til(A(;V'I'AN[< UISI1OSITlON "IUM KING RECiA(l) <br /> i / <br /> ,....r.........•.......................•• •••'.i.I.,,+++,tttf+++Jt.....y.♦ri..i F..r•q•.rt Y.Y. Y+...rt4 <br /> •'1.tFY11. <br /> 51:C TION I Public Ilc•aldt Service' I tnirclriuuadnl fluallh Division Tank "frncl:ig,, shed shall necornpany cath tank ;In,W:tl wiUi <br /> itr. site identification nurnher the "funk 'rjtw int; Shcct is to bc• rclumed to Public IlcRlth Services rnvironmenwl 1-Icn111l Division <br /> %Iithin_30 dl,s of ucccptancc of dw t.url; by 01c dislwsal nr Weycling facility Thr licrtnit hoNer is rmltnnslble for Crlsurirrg Ib(1 <br /> chis form Is complctcd and rctufrrcd. <br /> FACT)"rrY NAME:.-- !9 --� -- --- -----. . ...._---'---- — <br /> FACILITY ADDRESS; -� �P j� Ly.�........ <br /> TANK ID#39- 4l /,qD,5'TANK SIZE: PREVIOUS TANK CONTENTS:��f�jQlf,O / <br /> a+1141.f•4kW•��Y+•t+W#FrYk#M##444YiN44+4;W###4+sWwltW4W+YW#4#4##WY+nk+trt'44-+s•M+�#4Wt1•+W++4444'44W4f*+w##+t*+A•■+ <br /> SECTION 2 -To be Filled out by tank removal contractor: <br /> Tank Removal Contractor:—k—/---- <br /> Address: <br /> ontractor: /� //'�i�S �d �!!�/`t 0�✓ D -- <br /> Address; //7'30 )_ �y�Q�/,Qn( City Zip:�, �Q <br /> Phonc k': f"WDate Tank Removed: <br /> IF++♦+WWw•+4t4FwwKi44#•#•s•••s+Fw*r+#•#rt4*#4rt4##ss##+•sft WaN4#44wfK++<aW.+�d4MKt4#4###+�r.•s+Y•+Wr+rYr+wra.�44 <br /> SECTION 3 -To be filled out by contractor "decontaminating tank". <br /> Taal: Decontamination Contractor: �,j ele&IA[ <br /> City: Zip: <br /> Authorized rtpr(;sentative of cvntr.ctor certifying durougb signarure k1ov+that the tank has deco r n cd in an approvod <br /> I ra"i)cr at T<quircd by Cal EPA. <br /> Name I� DLkTM1S Ticic: �r22CTo�. Signature: Date <br /> ♦Nr.++Y+4,1,**1r.sR A+►i.A**t<R+I.Ir'r'rtt'.'i'M. 4+ 4*4 fk•4..rR+i++*Y+rt•r.4r'.w+'�krY t'.4vW►'#{.i.4+'S#M*44#%►t <br /> SECTION d To be signed End dated by an authorized represent olvc of the treatment, storage, or disposal facility <br /> i accepting tank and/or pipitlg <br /> Facility Name:� ���___J�m <br /> zip: --- <br /> Phonc <br /> bale Taal:P.1_ccived: :#/,2 , _----- <br /> Name: Talc:— Signa e;_ Date _ -- <br /> -.?k1a.YVr.li 7rr�v..Mn....v.r.�r.iM.Yrr•+}#+•♦�1�'ti'+/••'+tyt+cl�rt+TT►r•�'iIF�•�b+�+Y.1l�.i+�i+��rdF..1M*4rtr+l/1A.t►rtlR�+k'l i/+R <br /> 0111 (h.•'1•:.•:IQc')..t:q. J:t(N lU <br /> t <br /> 1 <br /> I <br /> t <br />