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<br />UNDERGROUND STORAGE TANG DISPOSITION TRACTONG RECORD
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<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 />rw1cling facility. The permit holder is responsible for ensuring that this form is completed and returned -
<br />FACILITY
<br />FACILITY ADDRESS: ";,W
<br />t (.(,( A%
<br />l-44—
<br />TA` K ID #39 - 4 SrI — OZ Tank Description:
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<br />SECTION 2 - To be f ��ed out by tank removal contracor.
<br />Tank Removal Conctactcr: ', //
<br />Address: (Z(2 S , � A ?� City. XI`J70 Zip: q5 a7J 0
<br />Phone #: (-?�x ) Z l 765` Date Tank
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<br />SECTION 3 - To be filled out by contractor'derapntarninating tank":
<br />Tank Decon=iinaricn Contractor: ��t D
<br />Address: (Z,1'7i r 2 ' S'-, City ��Sc % Zp: S S�
<br />Phone #: ( 2J 1) � I i(�-<3
<br />Authorized representative of concacor cerdrying through signature below that the tank has been decontaminated in an
<br />approved manner as required by Cal EPA.
<br />Signature- Title:
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<br />SECTION 4 - To be signed and dated by an authorized representadve of the treatment, storage, or disposal facility
<br />accepting tank and/or piping.
<br />Facility Name: L /(
<br />city Moil � zip: q U
<br />Phone #: (s"!0)
<br />Date Tank
<br />Title-
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<br />itle:
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<br />E4 Z3 049 (Revised 7-10-92) Page 10
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