Laserfiche WebLink
0 0 <br />UNDERGROUND STORAGE TANS DISPOSITION TRACE IG RECORD <br />........*aaa.... a....." I uaaaaa,saaaaaasasasaaasataa,asaasasaaaasaaaaasaaaasasaaaaasaaataasaaaa ..... *aaa. <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br />The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: Iu111610 <br />FACILITY ADDRESS: 3Z0 rj JhCL-3n J'+r2? } i "' 6 <br />TANK ID:39 - 1cVFS I - b li Tank Description: (y$ UUU Cu I l" dIeSZ f <br />....................a..........auasaaaua.au,aaaaaa.sa s.. a v.. a ...Acta... **aaa.. aaa a.* a aaa a a. a. a....... <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor: 5 C AS0 n <br />Address: 1 Zt • l Cj _4/ 22-f e.� City/, r v `t� . PS� Zip; e� S S l <br />Phone 1-: ( G01 ) s7i I' % lt{`l Date Tank Removed: /fit kki <br />�.................. a ....... ........ ......... aaa..a.a......... A ......... a,a.............. a.................. <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <,4t,(/1( 0 <br />Address: 12'k-) S : 7-41 S�ree'f City. M a Pr Zip: <br />Phone #: LZg ) <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved uner as required by Cal IEPA. <br />IVA�in A I 1 �AMn ^tAAAT� Title: <br />.... a u...... a a„ a...aaa..*......aa,aa.aa,a,a..a,a,aa...,a..,saa,.*.*.*.sa aa,** a. asa aa.a... a a a.*.. I . . . a a. <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping - <br />Facility Name: l <br />Address: 12,11S J U?� City. L zip: �SZ✓� � <br />Phone ': ( Zb`I) —'-2((�1�5 3 <br />Date Tank RecgIved: At4 - Ib <br />C. <br />..........*........................................................... <br />E4 23 049 (Revised 7-10-92) Page 10 <br />Title: PU.t&145k CC <br />