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FIRE <br /> Everett Fire Deparmtent - Fire Marshal's Office <br /> �ETl 2930 Wetmore Avenue Everett WA 98201- 7th Floor <br /> E- 11 <br /> PH. (425) 257-8120 FAX (425) 257-8139 www.everettfire.ora <br /> Tank Decommissioning Report <br /> Permit Number: 19001 i 6165611 <br /> This report is required to be completed by the current holder of an ICC UST Decommissioning Certificate who conducted or <br /> directly supervised the decommissioning work. <br /> Decommissioner's Name ENO ORC1291 1.1>U 1 ) (o <br /> Firm's Name I R001 bQ UROMI <br /> Decommissioner's Mailing Address 16661 0ROC)0U UI E RQ OU 00 UN I UI 1 DO gei ee <br /> ICC Underground Storage Tank Decommissioning Certification number: I I E I I 1 66I eee <br /> Address of Property Where Tank is located <br /> Address 121 e U»'�a>Q Ra)) City Ua»CST Zip del 6I <br /> Approximate Size of the Tank or Dimensions:eee G,±2 Approximate Age of Tank: <br /> Last Known Contents of the Tank: <br /> Date of Decommissioning: ell qII CAI I <br /> Type of Decommissioning: <br /> Removal <br /> Abandonment in Place <br /> ❑ Removed and Replaced with a New Tank <br /> Date of Pump and Rinse:en qn 61 <br /> Disposal Location(s): O O 2 p '1a>'�±3 a .__ ..F2 »la z o �%>e <br /> If Abandoned, Specify Type of Inert Fill Material: <br /> Concrete Slurry Other Inert Material (Specify): <br /> Sand O Foam <br /> Soil contamination observed:OrR O�z ,/�,/ s s ±z))�/4.2 o GIA6 <br /> Recommendation: O± o<(� ��®G, + O <br /> Location of Tank: OU A0»&+o s ±«- »O <br /> Decommissioner's Signature: �d� �G�� q4u� <br /> When report completed,please scan and email r port to: fmo(aeverettwa.gov <br /> REV.6.20.13 Tank Decommission Report <br />