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5-21-1997 3: 19PM FROM ALLSTAR/wESTSTAR 2092770106 P. 3
<br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<br /> SECTION 1 -Public Health Services Tracking Sheet will accompany each tank aubmd with Its site Identification number.
<br /> The Tracking Sheet Is to be returned to public Health SWAM within 39 dan of acceptance of the tank by the disponi or
<br /> recycling heWty. The pennk huffier Is responsible for ensdringrtot tick form Is completed 90 returned.
<br /> FACILITY NAfvsf?: n 1�t
<br /> FACILITY ADDRESS 7 7 FiaS7 o! /�iorir�o�7 37'/V041
<br /> TANK 1D#39- V K Tank Description:���
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<br /> SECTION 2 -To be titled outtrynk rymcontrayior:
<br /> Tank Removal Contractor. {/►lQ$fiwa
<br /> Mar c`n(Il_cvtMa(rfa( �hC.
<br /> Address: 20/ /77a/,,boa4 atue, City: d17aderr^ zip: ?3637
<br /> Phona N: ( ZDrj ) 47J-ci:x.1-8 Date Tank Removed:
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<br /> SECTION 3-Tb be filled out by contractor” afiglc L
<br /> Tank Decontamination Contracts:_ _ ta
<br /> _ 2e =ns tat*lu wyri�l cl -
<br /> Address: 20/ j'� t)rt✓-� City /"j�zap: 'Z36
<br /> Phone #-C7,09) &-I S- 93 SS
<br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated In an
<br /> approved maum as required by Cal EPA
<br /> Signature: �. r Title:Ts/Gfe�rf
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<br /> SECTION d-To be signed and dated by an authorlmd representative of the treatment,storage,or disposal facility
<br /> accepting tank and/or piping.
<br /> PadiityName: #Pj'Jn( ( _monyL /YIe/f�� CSO
<br /> Address* 1E.!j-1/U—r r �� alert 5 �� 46100j, sty re a o zip: 93 773 .
<br /> Phone #t:( 2D9 ) 3 7 — 4p� 7
<br /> Date Tank Received ct
<br /> Signature Titir. wry C
<br /> ........................................................................................................
<br /> EN V 049 (Rarland 7-10.92) Pon 10
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