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k <br /> UNDERGROUND STORAGE TANK CHECKLIST <br /> J <br /> Tank Size (gals'. )Tank ID # — <br /> Date Removed or Closed i <br /> Engineer Completing Form : <br /> Copy to T. W. Simon — SFO j <br /> R . W. Fish — WCRC <br /> I . Local Authority ( t <br /> Agency : r::/"! <br /> Contact Person : �c:•,�.�^ S ') )P_�r Date Contacted : <br /> Phone Number : <br /> _ Tank Closure Permitted : In Place C ] Removal <br /> Review Sign Off Form With -Local Authority <br /> l <br /> ! I . Contents of Tank \ <br /> Empty C 7 Contained Liquid S� <br /> Contents : / utF 7 . /<.;. " 'l. <br /> Contents Hazardous/ Yes C 7 No ' <br /> I <br /> Amount Removed (Gallons ) . �SG� Gr6< •ryr.0 <br /> Transporter Name : Entk7— <br /> EPA <br /> EPA 10 Number: C41) Q t Fa 392 <br /> TSD Faci I ity : ���� �' ��/. �i �� ff�f <br /> Contact Person : �Xk ,,;., <br /> Phone Number : . zllJ r22 � � JS/DU <br /> How Treated or. Disposed : <br /> EPA !D Number : C-4'E> 000zpei41 Z7/ <br /> i <br /> III . Tank Removal or Closure in Place ^ <br /> A: Local Inspectors = �Llc;a; C ) etIIn LIQ=f;/��n 91 <br /> Notified: /Ci <br /> Present Our i ng' Renova 1 JT 1 C <br /> Inspector ' s Comments : <br /> Documentation : <br /> s, I <br />