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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: <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 VON DALLAS GIGRICH <br /> Firm's Name TANKS BY DALLAS <br /> Decommissioner's Mailing Address 17552 BALLINGER WAY NE LK FOREST PK 98155 <br /> ICC Underground Storage Tank Decommissioning Certification number: 32US32003668 <br /> Address of Property Where Tank is located <br /> Address 6124 Larimer Rd. city Everett Zip 98208 <br /> Approximate Size of the Tank or Dimensions:300 gallon Approximate Age of Tank:50+ years <br /> Last Known Contents of the Tank: Heating oil <br /> Date of Decommissioning: 10/18/2023 <br /> Type of Decommissioning: <br /> Removal <br /> Abandonment in Place <br /> ❑ Removed and Replaced with a New Tank <br /> Date of Pump and Rinse: 10/18/2023 <br /> Disposal Location(S): N/A - tank decommissioned in place. <br /> If Abandoned, Specify Type of Inert Fill Material: <br /> Concrete Slurry Other Inert Material (Specify): <br /> Sand O Foam <br /> Soil contamination observed: N/A-tank decommissioned in place. <br /> Recommendation: No further action. <br /> Location of Tank: <br /> Decommissioner's Signature: t <br /> When report completed,please scan and email re rt o: fmo-everettwa.gov <br /> REV.6.20.13 Tank Decommission Report <br />