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0 <br /> INVIRONMENTAL HEALTH DuARt3�AYVEL� �. <br /> AUG 10 201 <br /> ENVIRONMENTAL. <br /> AC30i1£GRpO�dl� STORAGE TANK DISPOSITION TRACKING REC0RDliEA!:rHnFPA9T1rFK7 <br /> SECTION 1 Environmental Health Department's 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 <br /> completed and returned.. e - <br /> FACII.ITYNAME: <br /> FACILITY ADDRESS: ., <br /> TANK ID PREVIOUS TANK CONTENTS: O/ Sz!✓CI/� <br /> i <br /> i <br /> SECTION 2-To be filled out by tank removal cohtractor: <br /> Tank Removal Contractor: <br /> `/%✓J �/%^�7Q�� <br /> Address: p>i`1�7 66)>/r a5City:. 90 zip: <br /> Ph one#:(0a°I) Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: / ® 4JO \ -3 -52 City: G ✓P/ zip: qt-5� �� <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below that the tank s be de ontami ated in an approved <br /> manner asrequir-eddby1Cal EPA. <br /> Name: Z//�/ (V�.Title:�til�c9CllJ.2 —Z-�"�S <br /> SECTION 4-To be signed and dated by an authorized representative of treatme t stor e,or sposal facility <br /> accepting tank and/or piping, 9, <br /> Facility Name:- !ry' � -- /e0N4 e©_�y <br /> Address: 1®$��5 City: /�G ,J zip: �/ ��[�(� <br /> Phone#:( 20,Y) <br /> �a�'b ` r' n✓J 1?sy�1 *: Irl t� ��"�'/C�✓.✓a i��'f <br /> J. <br /> EH 23 046 (Revised$13/07) 10 <br />