REMOVAL_1993 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD t•t••t•4Dttt••tttttttlt!!lttlttt!•tt•tit•!tt••tt/!!t/\t!!llttttt/,t•ttt•tttttt ttltt t/tttttt•tt•tt••tttt„t• SECTION 1 - Public Health Services Tracking Sheet will accompany each Lank affixed with its site Identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facWty. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME:7/1G LITv D_ Te,Q�y FACILITY ADDRESS: G19 �qST fG FU �r/l r/ Tec - i 29C y c,4 S s37� TANK ID k39 - )Z /O — D1_ Tank Description: __-2 ) rO ` /, (A 1,'A \••\t\OAO\tt\t\•t\••I\•!t••••••••1•!. •.•,.•,..t.,,•,•.•,•.•.•••�•••.•..•,..•••••••••••\•••1•••t••t••••t••• SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor.__ �tJruE,b{T Fe1UrAJN�d-�iAL tUs t r../� Address:_ 196/ NJtt tl L / .47 City: rRiyL•�_ Zip: 49rs;7 Phone#:(Zbt7 Date Tank Removed: /p/ -z Z �q ,•\•,\••a••,•o•••p••••�••t••,t••.tit••t•u•••••..t••t./.•u.••t„•.••u•t••.•t••t••••tt...••t•••t,t••ttt.• SECTIO;? 3 - To be filled out by contractor 'decontaminating tank': Tank .De.Mntamination . Contractor: -- W R.C(s 01 r`_ AJV_U&M H �/)iA 4 eF,r?(lIG�S kddress:NO Prte V �E�1 �y City: i24 G V Zip: S.f 3 7,e Phone #: Authoriwd representative of contractor certifying through signature below that the tank has been decontaminated In an approved mannenas required by Cal EEA. . Title: Az:5ic�e t/ H •sss.lo0• itt••stsH•ttH•,.•.•..........t..•••!lt.N•t.r...t•!u••••••••,•.•••. •.••u s,t•bt•ta•Htu.• SECIIOi 1 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. FacilityNeme: T/Zr.1N6t f= of-- Se4 c e-4MeA)7-Q Address:_ /I JF City: S9C 2/I/yFitJTn Zip: 4S,?Z-? Phone #: q!6 1 4Z1- 1990 Date Tan Signatu: ...•l..c.•tt••a.........................•.....,............................•.!•... 0....,.............. ' 23 049 (Revised 7-10-92) Gage 10