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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />tiHttt Hittgtt tttt♦ttitttrttJiigtitiii•tittiit Httiitlt Ht Htti HtitY tltlt Hiti it tiiitgttiittgttittttt <br />SECTION 1 - Public Health Services Tracking Sheet will a000mpany 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:%//G 4 - X Op- r44Ac Y- <br />I <br />FACILITY ADDRESS: e $ EAST EL V 'N�7W ST.2CC / i 1MC s/ C.4 . r7J37Z <br />TANK ID #39 - /`/ 0 Tank Description:_ ;7-5—D &?iAj Cf/ /O ✓Avl�kL <br />rittiistttpistssitirsstttisirrii•iii••rrrr!ttttt)s•tttttirririsasstrrrirrrsrsssssriirrrsrtrrstrtrttii)iq• <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. LVkrb►IT XA.)t)TjP6Nr1EACT.41 S 000sG E S <br />11 <br />Address: /96/ NTLI flr&a(l W,+ City: TRAC✓ zip: �If37L <br />Phone #: -Z bel Date Tank Removed: <br />....arts!titstssiisstssstiiiitisttiiirtiiiti)••tttttiiiiiiiii••tttttrittiittts•iititiitiitt•tttt•iiitiiit) <br />SECTION 3 - To be filled out by contractor 'decontaminating tank': <br />Tank Decontamination Contractor: W Are'; 9 T r_Al VxLfM <br />Address: lul Ora Haat W�fiY city: T -94C zip:_ 4s37e <br />Phone #: ( zJ9 <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 />tttttittitpi gttt Httitittiittittttt Uttti Hittttttttitittiittititgtttt tttt•iittt ttttttiptttttttgiittt♦ <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: TRr gAjU k o ( AC,P+QMc.UiB <br />Address: 3525 S-? "-( /4J" City: S.9aAA)F.Vl'e) zip: 65923 <br />Phone #: (gl6 �_ InI- MC10 <br />Date Tank Received: <br />Title: <br />N titgtttiitttttii•Htttbtiti tiHttttltHiitr)ttttt tlttitttttHttttttY•ttittitttiti Rttti it)fptt li♦•tt <br />EH 23 049 (Revised 7.10-92) Pape 10 <br />