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JUL 0 5 1994 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ti+iaatrs+riiauarittrs;as;;Haat+as•ai+ttxri;r»i♦pat;xlr+t;•!i+•trotlxlxii;lirarsgtxt++lx+iaut+a!la to <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 <br /> holder is responssii�b�le/ for ensuring that this form <br /> (is'completed and returned. <br /> FACILITY NAME: / `j/o111W L3 <br /> FACILITY ADDRESS: 8l// /C, 111 / J3 7,,�< <br /> TANK ID #39 - 1lS30 —27/ Tank Description: f �QO tiSa-t°y t <br /> til++til;;xssirrattxri+tax;s»tisuaairiiastrrxx»itttxrrrislsagsaa;aait+atis Yairti;lsaf+aaxtx++i+isit++ti <br /> SECTION 2 - To be filled by tank removal contractor. (� <br /> Tank Removal Contractor: <br /> iL1 t�+� r111¢c 14t�3MZ_ �t�Ptlttt=S <br /> Address: �• Q• W7< 21 Yj City: 6 �(A^ Zip: 014V94- <br /> Phone #: � Date Tank Removed: J, <br /> Yi+ilii};ltiltiitltixtittixitltiiiiiilli;till!!lifttatttfiYitattttxxatiitittittttiali;iittaiilYitisilitiiri <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor_ <br /> Address: City: Zip: <br /> Phone #: (_) <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 /> Signature: Title: <br /> s+;+;iltitsasfa;riiittaltxfatsisisa-asaaitlsxxsaas»;f;sisw♦;rptx;aax»isi!!l;;ssaaaitwisar+Ya+isiasiast <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> Facility Name: <br /> accepting tank and/or pipin . <br /> Address: zSs Tt t �'^ L City <br /> Phone #: ( co ) 235 - 1>R it <br /> Date Tank Received: <br /> Signature: Title: <br /> ta;t;taaas;Y;siirarasYa}sills+s+arassaxisiaiaa»ia Yalxaiaialars;:a++rrrsi;saxfsaaalisil Yaiaxsla+siisaii! <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />