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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<br /> SEMON 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site Identification number.
<br /> The Tracking Sheet Isto
<br /> pe be returned to Public Health
<br /> recycling facility. Thea peServices A1111111 30 dors of acceptance of the tank by the disposal or
<br /> permit holder Is responsible for ensuring that this form Is completed and returned.
<br /> FACILITY NAME:---f-2 j2RI Lil-
<br /> FACILITY ADDRESS: -3,-2n'7
<br /> TANK ID #39. 1 n G G - a I Tank Description:_ G^,(nr)
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<br /> SECTION 2 -To be filled out by tank removal contractor:
<br /> Tank Removal Contractor:;"e �; •� L�V/�a= �rrF 7c ��� i� ,
<br /> Addressti��0 Mo. , "ZoP(',( ) �y City TGc�Crn,�J Zip:
<br /> Phone #: Date Tank Removed:
<br /> SECTION 3-To be filled out by contractor 'deconlatninaling tank':
<br /> Tank Decontamination contractor.STG 1x.1 `�-_Ititgt ��•:-a��i`,�
<br /> Address:_ DC7 /lrr,, CltyJr,J,-4 rou Zt .y�e
<br /> P•� +S
<br /> Phone #: (aO�i ) �fE q X33 S
<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.
<br /> Signature:
<br /> Title:
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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 lank and/or piping.
<br /> Facility Name:(--A6
<br /> S7, -/�
<br /> Address:/ U fl(`V7 City:�2t:ejL zip: %�
<br /> Phone #:
<br /> Date Tank Recely /
<br /> Signature:' Title: �� s
<br /> —�
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<br /> EH 23 049 (Revised 7.10-92) Papa 10
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