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0 <br />0 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />saiiiaf asaiawaai}ii isa iaa,}a aaaataa,a,sas as as asasasu sr. a}a as dna sr.»taasa,aaatas,asaa>asa,aasassisaaaaxaaww <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 holderis responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: P I onq P t 1.0 iyYo <br />FACILITY ADD <br />S . r71 W-K—T-lg ';�T . ( tpeym , CA - <br />TANK ID #39 - o I Tank Description: (0(vAL, CT?CES C <br />utxi•axwi a as t a a w...aaaaaaaa i i a as>aaa}>aaato aiia*alasatoa wa>a w w a a a a a a to l a w a a a a a a a a s iJ a a a w a a w a i.*.iiia a a a a a. <br />SECTION 2 - To be filled out <br />Tank Removal Contractor:_ <br />tank removal <br />contractor <br />Address:l2i? S� � 1 �T . <br />City: `zip: �S 0 <br />G <br />Phone l 76537 Date Tank <br />,}aataa}}}}}xaaai}1}}}w}a}}}a}nit}i}}.iia}i}}}}1}f}}}}}a}iai}}}i}}}}ta}}i}iw}}tif ilif}ii}}ii}a i}aaax}a}ata. <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: W/,tL6 <br />Address: l 1,1 '7 Sy r'7 TW SE City: �rc�=�'� 5� <br />Zip: <br />Phone #: ( 70n <br />Authorized representative of contractor certifying through signature below that the tank has beer. decontaminated in an <br />approved manner as required by Cal EPA <br />Title: <br />si}awaaaaasaisat aaxa>a>i}}a •aaaassaa,aaaaaaa»>aasaaa♦••aaaaaia,aa»iaaa>iaaaaaya•}a ta,ia�as iiaiasixa xatat <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 /u e-, <br />Address: (�u % City.�(�1UOI-I6� p; 6ty <br />Phone #: (_s—lo) <br />Date Tank Received: <br />signature: Title: <br />.a...............aa.....,,,,..,aa.a..,,..,.,.aa,...a..,........,a,...>...a.....a...a.a.aa...,,..,,>.x... <br />E4 23 049 (Revised 7-10-92) Page 10 <br />