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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />t.rt.••.•t.t..ti•t..tt..tr...t. tttrtt r.rr.rr..••.rt..•.r.t....»rtta..rt....t... tr...•rrt♦t..l..rt•r tt•rrr• <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank alf-med 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: %NC ZITv O" 7,64l <br />FACILITY ADDRESS: f 8 EAST Sneer, 7-/."9Cs{ C'4. IJ -37t/ <br />TANK ID #39 - _ ��I Q 0) Tank Description: 5(-9 e9ox <br />ttt.tt.••.ttrrta•.tttttr.lr.rrr»rt.u.ta••.•♦...»»..a•.. tttrgttttJ.•••b••t..r.ri»r..r••....tt..r•.t.... <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Con tractor: Wdu&MT rJ�1�QJN PAS%jC SECUsLES T_n/G. <br />Address:I961 flIc1, t/LEaf% W,+,l city: Zkxlc)/ Zip: 19 <br />Phone #: ZD 3' O7ScY Date Tank Removed: <br />a. r....*.tttt.rtttrtrtttrt.ttttt.tr...r.a..t.....at..tta...................r t a..... a.....,.......... <br />SECTION 3 - To be filled out by contractor "decontaminatingg tank': <br />Tank Decontamination Contractor: W Rb(s pl r r� YL�eDN H �rt1 iAG_ �FeUlCrS <br />Address: /i 61 dra VQSA)'WAy- City: F12A6/ Zip:_5'S374/ <br />Phone #: ( Z,>9) V 3 3 07-51 <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 />tttt ttittttttttttttt.ttttttt.tttlttlttlttttttp tltt t.tlttttttta tititttltttt tttttttt ttt ttttt.f tttttttt tt 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 />FacilityName: TiZT4/0U k of-- ,4 c44/Nc.,t)/o <br />Address: 3525 SZnd AJF City: _' c4aA/yE.y7o Zip: 9S8z-j, <br />Phone #: ( glib ) 11Z 1- 1950 <br />Date Tank Received: <br />Title: <br />•s.»tt•t•♦.stt..rrtr•rrr+»...,,.»r.»s,rta•»...............r.t.,.rr...»...........rru.ts.r..».»tsrs..». <br />EH 23 049 (Revised 7-10-92) Page 10 <br />