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,> SA- r OL?VfiY PUBLIC HE <br /> N JC .�LTI ..5 <br /> ltr6- . `�MEN 1 AL F-':.LTH D i'ISI'. ~��J <br /> L-N-DERGROUN-1) STC'; _GE 7r.-N–NK DISPOSIT Obi Tit_. . "I G RECORD <br /> . ./�,rw z�tzaKwwr*�wwwx,e***�Mt a[nexwwVex x: a.ala�t j[i[w Mak*leww*w*yewxwaexxw'kw Y.>jea iaxye�zx z.e.c.xac:+e�e lew.se MYw*+Kz�eMxµzx <br /> Public Health Se^i:ces Envirotune-::_._ Health Division Ta.�k T:ac:; :� S : sliall accpmpa y each tank aI xed <br /> idearrication naa:ber. The Tart: Traclin': eet is to :e returned to L gib':ic rie Ser.• ces Envire::r.:emal Health Divisicn <br /> in 30 dans C- accepiance of the tai< by the G.:: ;oral or recyclirg racilliry. .1e pe: holder :s respe Bible Ior ensuring z:a: <br /> -15 form is coruo e:ed ..ad recurred. <br /> FACILITY NAIME: <br /> FACILITY ADDRESS: <br /> SANK ID =`39 -�Of�3'OZ TANK SIZE:_ ./Z> IC- PREVIOUS TA\ ; NTENTS: <br /> xxz z'It ye.Mxzza.xzxzz*zz. ....*_ .a........ ... wxr:XaewM�z <br /> l.w r<xw:x Kzzzz <br /> SECTION 3 - To be filled out by tans; removal tractor: <br /> Removal <br /> Address: F5()g /yo . 1.� �lc9e�� _ Ci-.: %. i Z:r s— <br /> ?none . : ( Z�-r ; l.{�,Cfr_�� '-� :te Tank Removed: <br /> ..z+4z x�atiz.xx xzzzaa+sz+k:tzzzzzzz.zzx.Mx.Veal[ .....au — ---- xxxzzz..a[M%t ae ak lex*zea.:-a—-xx <br /> SECTION 3 - To be ;'Ied out by contractor "di-.:. lta'Minatirtg tank": <br /> 'anx Deccntami^a: or. Contractor:� "� C _ <br /> �� <br /> Address: &(?� [n. �utr ?^i Ci-.:ma y Zia: �'S' -09 <br /> ?hotie #: (Q2f _ elf — <br /> �Cnor:Zed- -epreseltauve or contrac.or Certlt`(ln,. :. :p:l1'1 S:Rr.<itlire t�elcw rt:a: the tai. . .s been c._conramirated 'ai an approved <br /> —=er as -ecu:red oy Cal EPA. <br /> Name: Title: Signar e: Date <br /> z,.,.,a.w*x+s:Mwe.,.wae 7e x.ee.:r:�e>,c:a.K sk a.x i.ax�wyR'x*wu... .:,.,K,sy�.vixxi*iwk>�xxyx t<>eY.ex>.x�:. .:x.•errssw�wkwa:*:aeKw�feasemww�=xae,.xxie <br /> SECTIO-; 4 - To be signed and dated by an aut:. ..-zed representative of trea:m. . ;tor age, o-disposal facility <br /> accepting tank and/or piping'. <br /> aclity Mame: C-A-�- C0&+� <br /> Acd�ess: 6o _ �.�. �r f.e! C �'= Z:p: S� C) <br /> ?hone #: (Zloq <br /> Date Tank Received: <br /> Narne: Title: S i gnan:re: Date <br /> zz,.,u,ezrwizYea[JlefMiii�tif]R�Cf�tllt]kf!tYwR�f([�el[%IK:k*ltlkielkz.... tfkie�t:C:illi[YL]Ie�ie)lefla(itli.KXYX%zfYfit]KI[x.: _ .x>fae�eMzkK*kKzzw[ML>/[wzleyeltItY[]KTtI[zz.Ky[ <br /> =H 33 046 (Revised 10/19/98) Page 10 <br />