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Dec-31 -02 11 - 14A Pac Fzeco Paste t }ndf ; ll P - 05 <br /> "A%-'JOAOl1fN COUNTN' PPBLit: 1!l:A1. 11 dLICvt( tti <br /> FN-v'1R0NMENTAI_W-A.LT11 DIVPf :f)NJ <br /> PNl)ERC120 uNll S'TOPACE TANK DISIN)SITION TRAL'KIN(: RwnRi) � <br /> ...a.....•r........._.•...........r.....r..............♦.....W.0......1..••srtsr►{rr.►r.r. <br /> rrrI*s r. <br /> 'WXTION I (Aublic Heald)Services Environmental Health Uivision Tank Tracking Slicer shall accumpany each lartk nffiKrd with <br /> Its site identificarion number The Tank Trat:kiug Shot! i.t to he rctumed to Public fie ilth Services Envirorurtental Health Division <br /> within.t0 days of acceptance of the lank by the disposal or recycling facility The pernelt holder is responsib;e for ensuring that <br /> this f vin is conplcwd and returned <br /> EACH-11 Y NAME _ --� oe <br /> FACILITY ADDRESS <br /> TANK ID 039- 01JL1L TANK SIZE:/IJ�pREVIOUS TANK CONTCNT-S. �/ <br /> tr•r•rrrrr.........Ir•..1{1.i•i•.rr...r+r`+'Iii..ai•..as.t►...ri..•►•.++.r...r.rrlsYe.arfli►r.r.r..+rtfkr4�+1t• <br /> SECTION Z"- 1'0 be filled out by tank removal contractor: <br /> Tank Removal C•ontr4LI01 A fit <br /> Address. 1 ��i4�1/ city.. <br /> Phone M: c2p�'�_ �2 q-510 Datc 'rank Rrmoved:_ <br /> rt.INs*r#i»1...riu.•►lep•+tt..•+.r...a..•t•.....r....N••s.ItNll.rrlr.r..�ry}rr.r1l is♦O••a.+♦+rt.•a+Ht♦ <br /> SECnOti 3 Tu he filled ow by Conti-Actor "deconlaminatine tank": <br /> Tank Tk-ontamination Conlraciot" ZSr <br /> + Address: City--/ a zip <br /> Phonc <br /> Authorized 11prtscasrive of coi racrot—ccniifying throu};h 5ignirure e :has been dccontalirinated u:an approves <br /> manner as rcot:ircd by Cal EPA. <br /> Namr. —- —Title:_ <br /> _signature: _ --Daze— <br /> ............ <br /> Date_............. •f..11111...•..}•..•......•..i...{.1l1.•t•....r+.1•+.•r.•1.}.i•i r.trlt <br /> SF(7110N 4 To he signnJ and dated by an authorized reprrsentatiic orche treatment, storage, or disposal facility <br /> t accepting lailk an(4/or piping_ <br /> FLcili'}' Nur:c 2 <br /> AdCress_ �1City: (9i`/� e' _ 7.ip <br /> Ph one or: <br /> 2 - <br /> Dalc Tank Rcceivcd. <br /> --- <br /> �L�if7l'.EL'��� Signature: Date-�OZ-- <br /> sr•MIi1.r......•........•...•.............•.........•..�.•f •r•.r�Nr .r 111.• .......... <br /> ..fir.a.•r 1411•.•1r♦r.♦ <br /> Vii, 1t) <br /> 1 <br />