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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> / .a.a.a.aJ..,..•�..arra•a,...a•••.••..♦.•,•.•.••.•.•.••P••...r.,•.•r..••.•u••••r••.••,r....a...r...a.a..r.. <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 enticing that this form is completed and returned. <br /> FACILITY NAME: T N E GS r� F- 772AC <br /> FACILITY ADDRES/S2 �� <br /> ES <br /> I S rQE rvv-t A <br /> TANK ID #39 - /t2 rD/ Tank Description: <br /> .....,....a•...........•.•.•.....................••..•.•...............••.r•............................... <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor. W IZ frNr G1v✓12 o n1MEnJ TAL SER Ud GC <br /> Address: 19 G 1 14 r t,L V t E✓j VJ4'1 city TIZAC U zip: 92-3 -76 <br /> Phone #: 01 ) 1933-07S5 Date Tank Removed: <br /> .......a........................................................................................•.......... <br /> SECTION 3-To be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor: nJ2t6-I{f r1J -T20A/MF/t)Ti1( SE 2VGGcS, LNC <br /> Address: /1&( /- cr( UiEu1 <br /> WA/ city Te.9cy zip: 37� <br /> Phone #: ( ?o` 1 5133 075 <br /> Authorized repr ntative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved titan r as . 1:4 y Cal EPA <br /> Signature: ^ Title:PIC5.1 e l - <br /> SECTION 4 - o be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: T2 EAN G L 1 0 F S,q CA AM EN70 CLI <br /> Address: 35Z 5- S Z A U r City- Zip: rJ-5 <br /> Phone #: ( 11I4 oz0 <br /> Date Tank Rece' (0_ 2 l p3 J <br /> Signat . - dN� Title: U � <br /> •....................•.................................•................................................ <br /> Ell 23 049 (Revised 7-10-92) P.ge 10 <br />