Laserfiche WebLink
UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />let••stYts,ssttrtttiprs,i,tat•a,tats•tssts•♦,ttrsti,„setrluti,tri!!♦iitstttts,ttite•rtssiittt!ltt,tui• <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 holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: V,0,bo Z3as /'is /A- P r <br />FACILITY ADDRESS: /21/0 <br />TANK ID #39 - // (— I �' rank Description:_ <br />t•MttttH,titttMtttttt•flittttiHt#„#tt Ytttttl4 t!ltttttAgtf ltisl i,tit•ttlltttititlstt,tttttt H!#tt,ttti <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: /vlt2;ifS�L /Ps �Ni/��cP S' <br />Address: -9,2-36,5 je5l Tro i�City: �1,i("e- fDre6-zip: 11,6)v <br />Phone #: Date Tank Removed: <br />,.,,ruu,attt♦•ttt••it!lt,t•est!!!!!,u•wt!!lt,tttt!•ru„it•t!!••tt•r••r••!!t„tttt!!!!!lut,sitsttra!!• <br />SECTION 3 - To be filled out by contractor "decontaminating tank”: <br />Tank Decontamination Contractor: <br />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 />lint,tiHt1♦,trHrtt#li,tttttta„ti�tti,t,HtH!ltittttt•tlNHitltt N,tttifiiti;R„lttiiitltttt•♦ttti Uri <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 <br />Address: City: Zip: <br />Phone #:( ) <br />Date Tank <br />Title: <br />N Htttttttittt Ntitgt NtiitittY;Mtttti Mtttiiirit;l,itit;tttltt,tii ttttY#tttittrtY ttt#,,,tititttti Nt <br />EN 23 049 (Revised 7-10-92) page 10 <br />