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SAN )I<QUIN COUNTY PUBLIC HEALTH SEROT&S <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*#*###******#######*****##**#####*****######***###***#########*####**##########****###*##########**###**### <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: 66-,Y4 l 1Z i( I N C. <br />FACILITY ADDRESS: 10 191, E S- 9 2 D U-ni <br />TANK ID (139 - ( ;Z--3,77- (TANK SIZE: I S 00 0 PREVIOUS TANK CONTENTS: C=n3G/L/+✓L` <br />, <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: P, D , -A301C 5,9-5S City: Q1 0J(2sl-O Zip: C 5,3 5;) - <br />Phone #: (Z D`I ) L52 tL � (a 5.3 Date Tank Removed: <br />C-a8_aoo► <br />################################################################### <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />############# <br />Tank Decontamination Contractor: n'� M C O <br />Address: C. D. -Qn k 15-2,5 5 City: M c J -831-o Zip: 0j'5352— <br />Phone <br />f535 2' <br />Phone N: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required y Cal EPA. <br />� v <br />Name: Title: Signatur Date <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 />Facility Name: w Tr1 <br />W �_ S l Copr <br />r 4 Q l Plitt �J i� i <br />Address: �I te�• ��lyy� kLr-�J r- Ido" City:_j-q OCfc Zip: <br />Phone N:) / �]� -- 79 <br />Date <br />Date Tank Received: P 1125 — <br />Name:� ) 0!:�5 Title: V Signature: <br />********#######***** <br />##*##*#***********###* <br />EH 23 046 (Revised 08/13/99) Page 10 <br />*******#####* <br />