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0 <br />• <br />LL.�4 11 w,. b &__ <br />ENVIRONMENTAL HEALTH DEPARTM,o�s <br />43okLL;QJAUSTORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - Tank Tracking Sheet shall accompany each tank affixed with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br />and returned. , <br />FACILITY <br />FACILITY <br />a <br />TANK ID 5-50 TANK SIZE: J 51-2 PREVIOUS <br />SECTION 2 - To be filled out by tank removal contractor: <br />CONTENTS: �G SSO 0/ L <br />Tank Removal Contractor: JJ `��/ �/zi�t-� ��r! 11V6 -/ ,, �+ ,/ > <br />Address: loo 3ox C3 �/ City: G�/,J I Zip: %5 4? T! <br />Phone P (20�) Z / `5 7 6 Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />� <br />Tank Decontamination� tractor. o/;Y, 7;7e/4 i'L^ o/L /Cn1G / <br />Address: PVx/ 3 Z -&)d / Zip: <br />Phone #: <br />Z <br />Authorized representative of contractor certifying through signature below that the tank <br />manner as required by Cal EPA. <br />SECTION 4 - To be signed and dated by an authorized representative of the <br />accepting tank and/or piping. <br />in an approved <br />disposal facility <br />or <br />Date Tank <br />Name: Title: Signature: Date <br />