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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> tit/trrs#tt/t*srff#t/##ts##ttti#/#ff##!t#sfsist#/#/tlttftits###/*fit#t/t/#/#tt#!##ft##r###ttstifstlt#i##tilf <br /> SECTION I - 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 dap of acceptance of the tank by the disposal or <br /> i recycling facility. The permit holder is responsible f�o-rr enstirtng that <br /> }this form is completed and returned. <br /> ILITY <br /> FACNAME: JAR(,) J U JAGJ,N -J£ LT1� 1 Za L t, aj <br /> FACII.1'I'Y ADDRESS: i <br /> TANK ID #34 - Tank Description;© Lc�.J '^��S (�ji(r `7?�r ✓G <br /> SECTION 2 - To be ffiledout b tank removal contractor: <br /> ' Tank Removal Contractor•. ,J e—S ©'- cc, <br /> Address: 'P403 6, fL�+o..�; /1J� City: Zip: 8370/ <br /> Phone #: ( Q .) `7 �' Date Tank Removed: <br /> a#r*rrr#sttti/sssssrrfttrf###rtrisst#*t#rsstrsts*itis###ft#rft#st#issss#sr#t#s##///ss#tff##tt##i/#//ss#*rrs <br /> SECTION 3 - To be filled out by contractor "decontaminating tank': <br /> Tank Decontamination Contractor. ")KS ct- C o <br /> Address: <br /> City: EL 5,. Zip; �1; ?0 <br /> Phone #: 9S' 34 S <br /> ' Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manlier as required by Cal EPA. <br /> 1 Signature, -t--- Title: <br /> � <br /> ' SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank an or piping. <br /> Facility Name: <br /> ' Address 610City: � '✓ Zip: <br /> /1 -2 <br /> Phone <br /> Date Tank Received: <br /> ' Signature: Title: <br /> ####t#ffff#f*#s#tt/sssstttt#s**#stf*est##ss#ffs#ss##ssssstssssrssssrsssrf##s#*srsttssssfsf#st*#t#/rsfs#f <br /> FH 23 049 (Revised 7-10-92) Page 10 <br />