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SAN 1,QUIN COUNTY PUBLIC HEALTH SER' ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rWMiMrtRYMRMMMMMRr#i!/iRiri/RRiMR\\Wi4rilrrWRrtYMIMi\#YRi##fiWMRMrtMYMrt/rrrrilMYrtRirRRiRiirtRYYfiRrtM4RMRRRrR/Blit <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affSaed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the [atilt by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: yos L d6n CQ1 <br /> FACILITY ADDRESS: 35c/ /vvI /7 ! y me, C 4 <br /> TANK ID#39 - TANK SIZE: �41)w PREVIOUS TANK CONTENTS: l <br /> WRMRYWiWRrRYrRRMRRRMRRYMWMIrtRiWiRMRRMRR!/ilii!i/YfiliifiiR#iirrtiYrfifiRMrtrrrIYYRYMM#RrRRRRRRifiYYrt\//RiiRRR/rtrtii <br /> SECTION 2-To be ftllcd out/bey taan'kk removal contractor: <br /> Tank Removall Contractor: [�Y_ . <br /> Address: `itlu5 //VA��l1 lNt�� 1L1 Ciry: G1� tt Zip: <br /> Phone p:� ( ) L1t07 Date Tank Removed: <br /> MrtrtWrri#Rr.rrt//rtrtirMRM•fiRrrrtrrirrtilYrtrtrtRM/rtrt/r/irt/rt.!//rtrrrYMrM/rrrrtrtrtrt/ir/rt/rtrrtYfii/i/rrtrtMRirtrfirtRrt/*rrtrtrrtRi <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: /-fla�[Qx �r{� �K u►�vtu/t %fes <br /> Address: 4 uS I4/ ��t��1 nW I]got) � City: Zip: <br /> Phone #: (�) `f 0— AV <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> irtrirt#RrtRrrrifiirtirfiRrlrt//R/iiRrti/iMM/rtirtrrtrrrrRrtrlrsalrrtiRRRrtMiRrrtrtrtrtRrti/rt\/lrrtRRrt/WrRRMrlRt4RRMi/RYRrt4irtrti <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: (/ �� Cfl�rs-f �9 M�F/T <br /> Address:_ 1 •O. 8p - ZiP <br /> Phone #: (CRO(y) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> rrirrtrrtrtr.rr+rrrr/r//////rrrfirrtrrfi.rwrfirrrir/r///rrlrrrrrrtrlrtrt/rtr/rrrtrtrtr»//r/rfir///rrr//wirt+rirrt/rtrrrrrrr <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />