REMOVAL_1995 - Laserfiche WebLink

Home Browse Search

r UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ........................................................................................................... SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAS: C NFJ�ad t oyl 61" I G�Y� C Axkr FACILITY ADDRESS: (CIOU TANK ID :39 - Tank Description: (0�0 (yaQ• J�E O SE Ute' SECTIOY ? - To be fillzd ou��o�ral cantraaor: Tank Removal Contractor." / ,/ Address: IV2 S ' -765f City. /�/�Olil e , zip: 'Ka s l Phone :: ( �7 ) f ,//�4(o �5 Date Tank Removed: ........................................................................................................... SECTION 3 - To be filled out by contractor 'decontaminating tank': Tank Decontacrnaticn Contractor: Sews) I Address: LZI �4 S� Cit�r. J 0-5T0 Zip: q<'- t P ha r,' #': Aur-horized representative of contactor certifying through signature below that the tank has been decontaminated in as aooroved manner as required by Cal EPA. Signature: Title: ........................................................................................................... SECTION 1 - To be signed and dated by an authorized representative of the treatment,storage, or disposal facility accepting tank and/or piping. Facility Name: q�-1 S ,�� S Address: 1&1(-, �-dt yejo ^" I City. Ode$h Zip: 4 35/ Phone I: C � ��✓7 -77�0� — Date Tank Received: >ignature• Title ........................................................................................................ E4 23 0-9 (Revised 7-is-92) Page in