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Dec-31 -02 11 : 14A Pacl-to Pass Landfill <br /> P - 04 <br /> ',Alms II)A(HtH'Nfl I'I.1rl.(, rlr �l.lf l,1"llFti <br /> I NV1RO)NA4r•.Nr'A1. 1lfAI.'r'Jr 1)1\'r.CfC1N <br /> 14NK DISI'OSMON 1'kA('K[N(: RP:COR,I) <br /> ....�. ... ............... <br /> Sli(.'TiU1' I I'uhh iicalll, %cn ice I.n�imnnlcnlal II,a11L Diulsv)v Tank hacking Sheet shall accompany rwch lank ;I ftxcd u jU, <br /> SIC!.,rc ulrnuLca;,,rt rntml,,•r I'lw -fall," Tr;tci.M:r. SlICc•t t;, he r(jun)cd kt r nhlic llcalth Survirc.t Enviroruncntal Hr;dllt I)ivts[Uq <br /> ."(thin 30-divs of accc{,tancc(it 0., 1,113. hr the tGclu,sz! u, tccychng lacihiv Thr I,crrnrl hnldcr is retpnntihtc for rmsurin8 that <br /> lhis form is Crunpi(-tc.l and rcwrrud <br /> FACII.IT Y NAME .1 <br /> FAC11.1TY ADDRESS: ZZ9 ��� <br /> 'fANK ID p'39.OILIPY 7-TANK sI�E.1��D� fZ PREVIOUS TANK CONTENTS: <br /> ..........a......s...►...slsYt....a.a..t................1YYY...YYt YYYI�M t.YY.l t1.i...#►..1.#►.♦..t►t#if1•#♦ <br /> SF.CTTt)!V J -To be fil&d out by Unl, removal contractor: <br /> Tank Runoval Contractor: <br /> Address: City ZIP:--J�7c7�- _ <br /> Darr.Tank Removed: <br /> •••♦Y.........♦.yt►...ir..♦.....r..1♦sty♦11.11�.'...tl iiit.....t#tI#t#IMI[#lt.t#t....1/i1Iw.Y.rt <br /> ♦Y4t.4..►Y#.Y <br /> SECTION 3 - To bc-filled oul by contractor ,dccC,nlautinafing tank„: <br /> Tank Dcconta Tjinalion Conlractor:_/ <br /> Address:��� <br /> Authorized rcl.:cwnumvv of contractor cem” ir,£ th;o„ h si azure bt- L [the[aril;ha; hecn dccoruarnmo.rd in an altkrovUi <br /> :Wanner a� rcqui:cd by Cal EFA <br /> Namc:-- — — fillet <br /> — — — — — gnatvre: Dice <br /> • .ysa.............s........ .............,......y..........,s........ <br /> •Y.tf... ............ <br /> Y. <br /> SEC'7'!O\4 7u tx ai�ncd and dac:1 by an authw"izcd rrprc5rntariyr of t),c treatment, storage, or dis�otial f:;ciliry <br /> 1 zccc�tinr tans:ar.G.'or {,i�,iu� / <br /> Addrest" Zip- _Z✓ � — <br /> Date Tank <br /> =-:Nantc: <br /> t nature: <br /> --,♦li..••I...y.r..r:...........Ys....R............ ......♦ •.�...a.iy ./•..s!•••#t.tl lt.Y ltt..f.♦#.. <br /> r <br />