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2-13-1996 1:40PM FROM FILL NER CONST INC 916 372 6984 <br />M <br />accomp"y each tank affi;wd with its site identifiCatioa number, <br />CnOM I - Public Health Scrvic= Tracldng Shect wx <br />rae Tracking Sheet is to b -t X-eturned to Public Health SeMces !!itbin 3_0 davs of a=ptance of the tauk by the disposal or <br />TeCycUng f2ctj�ty. The permit hol"r is re$p=ibje Wr ensuring that this form is CoMpleted and returned. <br />FACILMY NANM:- o"ki <br />FACIIZ17Y ADDRESS: <br />SEC=ON ;I . To be filled out by tank removal. contractor: <br />Tank Remowa ContracMr: Ft(-L4vA&2- , (fil-OM <br />Address:_yp 6 t- afwc 'Bk Ciry-._W_i_4q_C_ Zip- 7qe <br />Phone #- 37 7 - (74C Date Tank Rr- <br />SECMON 3 - To be Mled out -0y contracxor -decontaminating tank - <br />Tank Decontamination <br />Cj'Y' Zjp <br />Address: 1fD <br />—vk'mr, for- 11a.2"i <br />RE <br />throuth signature- Ne -low bat the tank has been decontawinaxed in an <br />Moir <br />'� , ffll Mffi� <br />SEMON 4 - TO be Signed and dated bY au autborimd rcpmsentative Of 01C treatment, $ToragcOF disposal facility <br />accepting tank aWOF PiPing. 41rr_ <br />Facility Name,.--- <br />,,,fir ID -f CAD 0 <br />q,Y <br />Ajddrew <br />M <br />11"MrPIMM-04M. - <br />Signature: <br />EM 23 049 L9ed 7-10-9?) Page 10 <br />