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UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD <br /> 404040#Iti1/0s0tt lf4t40stf tttttft0l*4t/st4tf*#01010110*0*0a s*1/t*/t of*ease 0*0000/004*00**000 s0/**ti0 0/1404• <br /> SECTION I - Public Health Services Tracldng Sheet will a000n;Pany each tank affixed with its site identification number. <br /> The Traddng Sheet is to be returned to Public Health Saviors within 30 days of aoaeptance of the tank by the disposal or <br /> recycling facility. The permlt holder Is responsible fcorr ensuring that this forni is completed and returned. <br /> FAcaxrY NAME: —'5qrJ Sa A Q J N - L'T'A Ca C L <br /> FACE=ADDRESS: <br /> TANK ID #39- ,�G I Tank Descri,ptioa: rJ CLo,J S7'� C7/L 77��/C <br /> 4ttti4ii*0t0tMtlttt4*tsistttttlfft4i*#Mfti0tftlf*f00tst0stt4100*0*001t*tt*t 00*4ss*s;so***f*400*0*.**0000*00# <br /> SECTION Z -To be filled out by tank removal contractor. <br /> Tank Removal Contractor. nl--s <br /> e�,SN© : Q 3'707/ <br /> Address: City: �' zip. <br /> Phone : (� ) `y 4r•J�. Date Tai&Remcrv+ed: 0 9 `�v J /v <br /> �sssssssss4*ss"sssitssfsf �siss� ssf !'i*i lis[isssisi��Y'#+ s1ls"ss`ss�ssssssssttsstsftsssssll/ <br /> SFCMON 3-To be filled out.by.contractor*dceontanunaitng tank': <br /> Tiihk`Decontamination Colttractor <br /> city: FeE Sn-�D Zip: Q3 -20, <br /> Phone <br /> Authoiiwd representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> app <br /> man as i4ji ocl�by_Cal EPA._ <br /> Signature: <br /> tttttf04444#ti*i4ff*0i4tiiii4t4si4t4***0040*♦ftt/000040*t#tt100tttttst*#tiit4t*444*4t0t4t4t444tIt*tttt 0040• <br /> SECTFON 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> aocep " g tank and/or piping. <br /> Facility Name: <br /> ' Address: f lu / cu%Grf�` f ary: l� G�G7 lap: <br /> ' Phone #: fL-3 ! S -3 7 <br /> mate Tank Received: <br /> I U <br /> ' Signature: / 1 Title: <br /> t0ttt4sssssttsttttrsttts 00140 ase♦ttsrsrrstsssssrr.ssrsss.........ss.usstttssttssrsrs . ass.sssssrssstssss <br /> Eli 23 049 (Revised 7-10-92) Pagc 10 <br />