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.. <br />Telephone: (209) 468-3420 pax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - SIC Enviromnental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br />completed and returned. <br />FACILITY NAME: f1 G <br />FACILITY <br />e L L C, <br />�, <br />537L- <br />1 �' r <br />TANK ID #39 TANK SIZE: PREVIOUS TANK CONTENTS: 1_61 16 CIA <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: �;45-lf1�'l` � ftlf Y. -L. <br />Address: ye. Zip: �J�Jf;t} <br />� 7 I J (= �� iii lS f ./� Ci If��� ty � <br />Phone #: GL c t } > > ( Date Tank Removed: /0 _4- o � -- <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Phone #: ( ZC' <br />-' - <br />r_? -� 3 C:75 . <br />City: l' d Zip: <br />Authorized representative of contractor certifying through signature below that the <br />manner as required by Cal EPA. <br />Name,V�p " A C I I Title: -C'51.1:( -Z Signature:_ <br />SECTION 4 - To be signed and dated by an authorized representative of the trey <br />accepting tank and/or piping. <br />Facility Name:�qq�t>� C( CVSA <br />AAA-� (7zi lCVlilr <br />,c <br />Phone #: ( k_ <br />Date Tank <br />_d <br />has been decontaminated in an approved <br />storage, or disposal facility <br />city: i A ! G Zip: <br />Name: Title: <br />Signature:7ZW_1 <br />EH 23 046 (Revised 12/31/07) 10 <br />5;' a <br />