Laserfiche WebLink
UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed 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 /> FAcamNAME: % -"itio /�11�w+yA54i)ifo m1d Uwnrr Ooioo I <br /> FACU TIY ADDRESS: 5� cJ t11Y MM <br /> TANK ID N39 • Tank Description: /& <br /> SECTION 2 -Tb be filled out by to removal contractor: <br /> Tank Removal Contractor. t�t E(nGLfLhQ� Q r'C, <br /> Addraa �{ City:'Rl i6f1 zip: n ' <br /> �lL(o <br /> Phone 0: (9�)q 1 -7 Date Tank Removed: <br /> SSLTION 3 - Tb be Hued out by Do tract 'd Laminating ttink': <br /> Tank Decontamination Contractor. L�Zt" <br /> Addren: 1 d0 � City:_ <br /> Phone A y�W-,12�7 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved )Wanner as required by Cal EPA. <br /> Sipafure: Title: <br /> r••••prr•••••••••r••••••r•••••••••••••••rr••••u••••••r•••r••urr•••••••••••••••r••u•r•••r••••rr•••q••r• <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 Nam*:--- „ p�(� d6 <br /> Addreac_ f DGU( ///011pp'7�, lD�l/�7/1O City: Zip: <br /> Phone #: (_ b (��0 <br /> Date Tank Received: <br /> Slgnatura Title: <br /> Ea 23 OW (Mwlwd 7-10-92) i•ar 10 <br /> v» <br />