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HLL31HK YGIKULtUi'I t4[UlY Ztl`l Z ( (Ultlb Y W0 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> HHH•tHH�ab.H.HH HIH iaHHr>aHH♦HHH.H.f.HHHt•HH.HHb N.•t•HHrH.HHt••trf.H.••tt• <br /> SECTION I - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking Shea Is to be returned to Public Health Services wkhh 30 days of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder Is responsible for easdring that this foss is completed and returned. <br /> FACILITY NAMM_4jCjjS, 1 <br /> �A0, E_ <br /> O ' <br /> FAMI7YADDRESS: g7 %Cq UI Aowoq WLr L?ZM,4Lh <br /> 7lGGt —Y22 <br /> TANK ID 4139- UI< Tank Description: &aiz <br /> •.HH•HHHH•tft••HH•rHf HtaH.H.rH...•.HuttH•HHHHft.•t<aafre•fawai.•t.a•s•s..•sfHH•HH <br /> SRCT[ON 2 -To be filled out ick[q cones r: <br /> Tank Removal Ountractor. n <br /> Address: 20/ /r �� <br /> 1h,,7 ✓ fi lug City: gde(cl\ zip: '/3�c37 <br /> Phone #: ( Zoll 1 (P �?351� Date Tank Removed: <br /> Hr•HtH.H•HtH tH•HHHH••H•H.•.••ftfir••....rHHHHHH•HHH.H.HHHH•H.HHHf H.H.Ht•• <br /> SFZTJON 9 -To be filled out by contractor'"d ntaml ting to f. <br /> Tank Decontamieation fJaatractor. YUees� <br /> Address: �ZOf 17)Glnbeir1/ 0ntj-e sty: /4fi1defC-,zip: <br /> Phone #: ( 20 r) 6?7'3�' (%3S8 <br /> Autborbed 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: r Titie:�P,�l Pelt <br /> tMHlHHf• tHH.N•HtlftttHHtH tttUHMHHHf Haat Hca HaHtiHtttHNaHa♦•Hiatt.Hitt tt t.t a•H• <br /> SECTION 4 - To be signed and dated by an authorized represeutathe Of the treatment,storage.or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: PL}l—_ (pn u--Irtld—a/ 0 <br /> nddreta:l 4}L'��/!U 'n She. ��tio�• sty tee i�e zip: 93 773 . <br /> Phone #.i I D9 ) .Z 3 I (a(O -/ 7 <br /> Nate Tank Received: <br /> Signature: rile: <br /> 4040 a•<•t•.•.t•f.04t.t1•t.at•.•f•t•aata.l..t•.•tar <br /> EN 23 049 (Ravleed 7.10-92) Page 10 <br />