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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> /r.H••.a.M..as.rr...laf...J.u.a....H.»•H•.......••....Ht H••q••t.t.r t.•H.....,..aa1..H•......Ht.• <br /> v SECTION 1 - Public Health Services Tracking Sheet will accompany each tank awed with its site identification number. <br /> The Tracking Sheer is to be returned to Public Health Services within 30 dun of acceptance of the tank by the disposal or <br /> recycling facility. 'Ile permit holder is responsible for casuring that this form is completed and returned <br /> ®FACILITY NAME: 0-#,jA � <br /> r 1 S (25 ,ti 41 A <br /> &ACILITY ADDRESS: 14t trune r- S } <br /> ©&TANK ID 039 - Z3-7 _Tank Descriptio S1nJ <br /> SECTION 2 .To be filledgyby tank removal contractor. <br /> Tank Removal Conuacto i Sc ,k C-TJ V t iC�r3 v..tib t� <br /> v <br /> Address: IO40 We!gi-- t�(4ww�u N_ Ci �-o�, Z Olsz 1D <br /> 9 Phone 4t. 2( oq 1 ji r - 3 b 1 - S(o� Date Tank Removed: <br /> - (................. .........................................................a........................ <br /> .....a. <br /> J SECTION 3 -To be filled out by conqBQor*decontaminating lank': <br /> Tank Decontamination Contractor.] R1! <br /> I&Address: Z13S PcL,-y 01�)iD G1cy(�7 RlGti-f'tciND Zitg>< ) qt/A,{?/ <br /> &hone <br /> EaAuthorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> pprovod manner as required by Cal FPA <br /> ,Signature: TtL— <br /> •.Nu..HHr.....R.,H..o•.PYr O...•tM HNa.a.l.Ywb.w.at.H.....a.tt.N.tM..t..••......a.Nuu <br /> SECTION 4 - To be sipped and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank piping. <br /> scilityName: G'Yf G l�soA1 C}JV tV2�i�l rrti.J ' a tJ <br /> cis Address: 25,,E Pavy- � .l n City. Zip: <br /> {�AAVVIP�hone #: (S l'J <br /> (ZWate Tank Received: <br /> Signature Titre: <br /> .....................v•.............r.rr.•raw...u..•atl..•w......................................... <br /> EA 23 O49 (aeviaed 7.10-92) Ve0e 10 <br />