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y 0 ATTACHMENT :5 �' <br /> DOCUMENTATION OF DISPOSAL MAR 10 <br /> OF UNDERGROUND TANKS & PIPING <br /> Facility Name : _ Phone: (:.)c�j <br /> Address : qsr� C'. City: 5Lc. <br /> Tanks Removed : Size Product StoredDate Removed <br /> 1 . J <br /> Gals . 3 <br /> 2 . Gals . <br /> 3 Gals <br /> 4 . Gals . <br /> 5 . Gals. <br /> 6 . Gals . <br /> Tanks disocsed of at hazardous waste facility* ( ) Yes { ) No <br /> Name; Address City: <br /> *Attach ccov of manifest <br /> Tanks disposed of at a recycling/scrap facility { ) Yes { ) No <br /> Name : Address : Citv: <br /> f <br /> Tanks sold (" ) Yes ( X) No <br /> New Owner:-� ,` +. ,— Address 444V /tom City: G%•u�: � �'/ <br /> Nature of reuse of tanks : _,r' /,�• <br /> SIGNATURE: Un DATE: <br /> PRINT NAME: <br /> Please return to : - <br /> i <br />