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Dec-31 -02 11 14A Pa( hc,, c, ill <br /> P - 03 <br /> I I FA 14SVP <br /> Iff-AL'I'll MV4,510N <br /> ''N' Nk DISTMI VION TRA Rt-.( 1)k 1) <br /> ............................... .......... ....................................... <br /> J'J!J)fi' tiC-1 Vitt.% i)-tsion Tia Ti;cking Shed ';h;'11 ;"-OMPADY each tank afiied ilh <br /> 'S I I C 0C I IN(IL J h.,n I I I I I I I I I)c! 1?!c T.i 14 i-I I I 19 h-i iw returned lo Pulilic llt;afth Services ]]call); Division <br /> U1114-iff 30ff:1j s U; ..(:CL:pl.'n'.0 t'(Oil- Iml) .y�1n,F1261ijy The pernW hnld4r.r is f(, ponji!)IC for ensuring that <br /> this I0rTn VS cnfrjp:(fj-d and iciuriico <br /> I-M-11-11 Y NAME- <br /> FACILITY ADDRESS <br /> TANK M#39 <br /> 4YP T-A N K SIZE: VIOUS-rANK CONTENT'S�J., <br /> �PRL <br /> ................. <br /> SECTION 2 :-Tci be filled out by tank removal contractor: <br /> Tank Rrrnoval Colitracror <br /> A-1 <br /> Address:_ <br /> • zip� <br /> Phone City <br /> Date Tank Removed, <br /> ......too <br /> SEC71­10N 3-To be filled out by contractor "decontaminating <br /> Tarlk- Dcr�onurnination Contr-Acinj: <br /> Addre <br /> City:jaA4de---1&-Zjp--­- <br /> Phone#:al 7 ;r _ <br /> Authoro-co r , <br /> of cenif%,mul tllrot--gh .,.ignxure Vw-�jw owx th, tail <br /> j.dccontamin2jr- <br /> MITI—as requixrd hy Cal EPA hi ajiapprovM <br /> Name Anatu lmc <br /> .a I <br /> To --nt-ea;cdby aiiau(Ituri,7rdrel,i-e.scnU-fi%cofthe treatmClit,slnragr. or di' <br /> a-ttp(ijif,la'ik pipin- <br /> FVJlity Name -����� -_��- ` �,��// -- <br /> Addi-L7ss- <br /> Petr <br /> zir�: <br /> Tank R­tC;xjj: <br /> Nan K:: <br /> Titic.-Yi7dAl"L/2— <br /> ........... ........ ....... ...... ........ ... ...... <br /> Ell-23("I,-; <br />