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ATTACHMENT #5 <br /> uu <br /> LOFUNDERGROUND <br /> MENTATION OF DISPOSAL MAR 101989 <br /> TANKS & PIPING <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> � <br /> Phone: 3 <br /> Facility Name: o q ) .3 y1� <br /> Address: Cr _City:- �' G1 7� . <br /> Tanks Removed: ize Product Stored D—a—t T Removed <br /> 1 . Gals . <br /> 2 . Gals . <br /> 3 . Gals. <br /> 4 . Gals. <br /> 5 . Gals. , <br /> 6 . Gals. <br /> Tanks disposed of at hazardous waste facility* ( ) Yes ( ) No <br /> Name: Address : City: <br /> *Attach ccoy of manifest <br /> Tanks disposed of at a recycling/scrap facility ( ) Yes ) No <br /> Name : Address: C' tv: <br /> Tanks sold ( ) Yes ( g) No <br /> 57 <br /> New Owner: r AddressCity: <br /> Nature of reuse of tanks : <br /> ' <br /> SIGNATURE: , �G= DATE• <br /> PRINT NAME: <br /> Please return to: <br /> .� .[."'r' ypvl+'F TRP!!!ryn -...Ns" 'ry`R7s f -^r "•'.' r^r+Y'f} w.�..*.e_,Ryma:ti" <br /> ^f!"[ '. �•' Y L\ u+srrr✓�—+ �M ab6..,�+ p <br /> q,+ l Pe v+ rvr .. ..( ' v.-' }p� F� 'ba'4 W^+ ,"'1�Af'�rl"1.[�1���..a'T��'d)Zf��'y)a�>.� ✓�'T..�. <br /> `J.�;.., T -a.;i' �v :... ... <br />