REMOVAL_1996 - Laserfiche WebLink

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�..� .10, UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD itarra!!!;44srsirrrrli!!!i}};iriwiw#!4lss};;rt»wsrswrtsrr»»rririi»rrrrrrsiiiirarri!};s#x;4»rrrr;•;;}sstss;lar SECTION 1 - Public Health Services Tracking Sheet will accompany each tank 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 facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: PIEDMONT LUMBER & MILL CO.,INC. FACILITY ADDRESS: 7777 WEST ELEVENTH STREET, TRACY, CALIFORNIA 95376 TANK ID #39 - Tank Description: 340 r-Al LMI (--L1SC)LiNF »rtilwwwwwr#iiiirriiriix##!;;};;}};4}i}#;;i#;;44;»x4it}i4;;;;;;;};}#!i}iltiiirw»rir#wiirli!!!!!i!;»;;;ixrrir SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: AAWC WBLiTZELL Address: BOX 30331 City: STOCKTON Zip: 95213 Phone #: ( 209 ) 943 7793 Date Tank Removed: ir»r»r»»r»rwrirrrsrs»rrrrrwrrr!!•!•rilrir!!aril!rail•riwrirsr;;}4}!}ri!!lrisiiwwwr»»r4»rtrw}»}www»witrrrsrr• SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: SAME AS SECTION 2 ABOVE Address: City: Zip: Phone #: ( Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Signature: Title: ssi}t#rt44;s}s»xrt}s}»;4;i#;}#l4;x}x}#;#x;;!!}ilit!!lstiwiy;}rt}}#isiiri##wtw}rti;lsi!!:i#4rtw}#}}sirii!#lissi!• SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: CAL COAST TANK MFG. Address: 424 S. TEGNER ROAD City: TURLOCK Zip: 95381 Phone #: ( 209 ) 668 9378 Date Tank Received: Signature: Title: ER 23 049 (Revised 7-10-92) Paye FOURTEEN