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Uti/2tf/4UUJ LHIJ U7 4b YAA foil JVJ JbJ4 MY hNVIKUNMENIAL-13AK 0008/012 <br /> N® 10988 <br /> GOLDEN STATE METALS, INC TANK DISPOSAL FORM <br /> P O Bax 70158 • 2000 E Brundage Lane Date <br /> Bakersfield,California 93387 <br /> Phone(805)327.3559 • Fax(8051 327-5749 Contractor' <br /> Scrap Metals Processing A Recycling License No <br /> Contractor's <br /> Phone No <br /> CONTRACTOR: <br /> ADDRESS: Lu <br /> JOB SITE t <br /> ADDRESS, Q <br /> DESTINATION G S M 2000 E.BRUNDAGE LANE BAKERSFIELD,CA 93387 <br /> HAULER " krQ LICENSE NO <br /> WEIGHT CERT NORECEIVED <br /> EFfSD PERMIT NO, <br /> QTY GALLONS SEIRIALNO NE l TONS TOTAL <br /> 14 <br /> COUNTY �t <br /> 550 24 <br /> N' SERVICES RENDERED COSTtq <br /> 1000-6 ft ry' b1 <br /> TA IDECTION <br /> CLEAN&DRY(ACCEPT),OR 2000 BT <br /> ❑ RESIDUALS PRESENT(REJECT) 3009 122 <br /> W W4 <br /> LEL RFA-GING 5040 242 <br /> OXYGEN CONTENT 7500 329 � <br /> DISPOSAL FEE <br /> 9000 482 <br /> SCRAP VALUl; :ale„ <br /> 12000 403 <br /> K <br /> OTHER - <br /> TOTALCH . _ TOTAL <br /> All fees Incurred are per load unless specified Terms are <br /> net 30 days from reaelpt of tank. Contractor's signature <br /> representsaooeptanceofterms for payment,and confIrma <br /> That tank removal complies with State laws. " <br /> M <br /> +waaaa�.o <br /> CONT ACTOR'S SIGNATURE <br /> CERTIFICATE OF TANK DISPOSAL / DESTRUCTION <br /> IS W TO CERTIFY THE Ii IPT AND ACCEPTANCE OF THE TANK(S)AS SPECIFIED ABOVE ALL MATERIAL SPECIFIED WILL BE COMPLETELY <br /> E9TRO FOR RAP YCLING PURPOSES ONLY. <br /> 1JJxxx/ X, <br /> AUTHORIZED REP DATE <br />