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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank afruced 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 holder is responsible for ensuring that this form is completed and returned.
<br /> FACILITY NAME: I '//I�'yd Dy'd'l ,,
<br /> FACILITY ADDRESS: Dµ95 1��1kbn j-j-fh &t53d�P
<br /> TANK ID #39 - Tank Description:—;--LX6
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<br /> SECTION 2 - To be filled out brank removal contractor: �"
<br /> Tank Removal Contractor: �IQ1-V(�I + 9)(Q ,l 4inn OD TnC ��"
<br /> Address: o(kl�� �nOh c) City: Zip: (]5AO
<br /> Phone #: c 90 , 5qq-a--3+-7 Date Tank Removed:
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<br /> SECTION 3 - To be filled out by contract "decontaminating tank": p.
<br /> Tank Decontamination Contractor: a jy{ � tl n U! T (1
<br /> Address: e[IU 7 L)YPfaDYI City:. Zip: q'j—�j(�(p
<br /> Phone #: cZL 5Rq- .12Z4-7
<br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an
<br /> approved manner as required by Cal EPA trnrn
<br /> Signature: Title: t V
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<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:_ Cal - N5L 04 .
<br /> Address: /, 15�d LmW6Dd City: Zip: gS�Q�p
<br /> Phone #: d
<br /> Date Tank Received:
<br /> Signature: Title:
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<br /> EH 23 049 (Revised 7-10-92) Pape 10
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