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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />tttttrtrrttrrrrrtrtttrttttttt•ttttrrrttrrrrrr•t••••t••••ttrtt+ttttrrtrrtrtrrrrttttrttt•tttrtttttttttrtrtrt• <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 NAME: 7//c LITy OF- r -UA Y <br />FACILITY ADDRESS: i; $ EAS% ELFr/F.d7f1 ST.ect/ - 74MCV G4. 49J37L <br />� <br />j ,r 7 <br />TANK ID #39 - I yIO— l) Tank Description: 1 t/ Gj,G� <br />A <br />t•t♦•rtttpttttrtrrsttttt•t••xtttpru+rttttirt♦t••ttt•at••ttrtutrtt•tr♦ttttYttt•strtrttstrrrtttttttrtttt• <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. LU.QLb NT AAJt)re9)A i, eAlTil <br />Address: /,?&I P-rtt_ dr&A# u/.AJ City: 192K / , Zip: 49S37! <br />Phone #: ? 0 833- 6 58 Date Tank Removed: <br />tttittt•t••torr•rtrt♦•ttttrutttti•ttr•rttrrrr•rititt•ti•iririritrtr•utp•iir•rtrtrrriurtttrtttttttrtttt <br />SECTION 3 - To be filled out by contractor "decontaminating tank': <br />Tank Decontamination Contractor. WAE&91- t=_tllV.L.2DAJ <br />Address:I4L/ Nils VrEcU 'WRy City: 7-2RG) Zip: f -1-37e <br />Phone#:( 709 ) 4f33- 0'75g <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 />Title: <br />tt•ttttittt•♦ttttrttttttttttf tt ttttitl tttKtrtttHttHttHttt•ttttttrttr tilt tttttttrtgttttt•Mt1tHHtr•tt <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: 7'IZXAA)6t E O r- 5.44i±4Mr.U7-6 <br />Address: 3Sz5 z,z^°� AtfF_City S9tAA^)rVI Zip: 9SfIZ3 <br />Phone #: ( 416 ) QZ I - 1990 <br />Date Tank <br />Signature: Title: <br />itiirtttigttrttttNrttrtt•tt irrtttttrr••itrr•••s+i•i•I1•ttt+tt+♦•tirritrtt•t Hlt++rttrrttttttttttttt••• <br />ER 23 049 (Revised 7-10-92) Pape 10 <br />