Laserfiche WebLink
..- <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />rslsgrrslrt#rssttttslaarrrrss•sr•trsurr##•trrlert•r••srtrY!!s••ttt•ss•selt•r!slpr•rrrstr•rt, ttsraugtY• <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 />FACILITY <br />FACILITY <br />TANK 10 #39 - J-/1 1 V Tank Description: /VUV ! ,j Z / fdjG/ /z2 -l4/1 61. 5-/ <br />sru•!rr#tussatrltt••trlrrrs•t##rr!!••asu•lu,a.,..rr•r•r,•r•r•s!!rt•,rr#rr!!!••rar„r„rlrrrr••u!!•!!•q <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: /1% i P ST'S %PcLivrl�x/FC %irc_ <br />Address: _2� GS <br />7,10 <br />re- <br />city/ aAt-,1'vesT Zip: (F Z i j30 <br />t°E� <br />Phone #; (7��i 1 4(,5q— <br />7 <br />1300 <br />Date Tank Removed: <br />••r•a•tatsrtrr rrttttttttt rrrrsu!••••,r••au•,r••••••••!••rt,••u.••!r••rr•!r••lrrrt•••r,•,•, r•••,s•s•••r <br />SECTION 3 - To be filled out by contractor <br />Tank Decontamination Contractor: <br />Address: 22365 EL Tomo Vim' -city: t f��i�sT�p; gZG-?o <br />Phone #: ( ")Iq ) !/.S�f— /30d <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: Title: /1�%6T_!l� c� _P— <br />a <br />rtslttt•tttrttttrtsrrttttttutut•tur!•trwrrrrrrt#ttttwtYttusraa!•trrsaa!•!!s!lsurttutttrrrttrnttttt <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 Nt <br />121 <br />1 <br />'�I/^` City: l! CCY �, Zip: <br />Phone #: ' tl <br />Date Tank <br />Signature: Title: <br />tt tltttrHtttipggttqttttqtqt?tlrt#titRtttt YtyitrrttYtttttlNttt!••ltttltrt#trtt###!t!##t##ltttttlt <br />ER 23 049 (Revleed 7.10-92) Pape 10 <br />