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UNDERGROUND STORAGE TANK DISPOSPTION TRACEaNG RECORD <br /> •aa»aaaaaw>wassa;aaaaxaaseasaaaasaasaaaaaausasiwsaasaaaaawaaaaassa>aaaaaaaaaaaauaaaaass;aaaswaaas»»Yaa <br /> SECTION 1 - Public Health Services 'Tracking Sheet will accompany each rank affixed with its site identification number <br /> The Tracking Sheet s 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 responsibleforensuring that this form is completed and returned. <br /> FACILITY NAME ;5�.: 6 `D ZTT/ TfiL•�+� f l <br /> FACILITY ADDRESS: �7 9 Gc G c <br /> TANK ID #39 - /7-2-�76 Z) Tank Description:_6.nnn as 11 on si nal p 1 t t, <br /> sxaa#sasaYY#assxsaa>YsawYasaiaa;aaa>Yawxiaxwa>aaaaa>wa;aaiaaaaaaasasaa»ssaaaasaxaaa>Ya>aaas##sx>sawaasxrsx# <br /> SECITON 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. Advanced Envirormental Services, Inc. <br /> Address: 1419 North Market Blvd. , Suite 5 City Sacramento Zip: 95834-0457 <br /> Phone #: ( 916 ) 928_8300 Date Tank Removed- <br /> •saaas»xxxaaass•aswa»w#»wa#Yaisiaxwaasssas#sasws>isriwa»aawas•sswaaasaaaxsswaasx#axsa#s»sxaaaix#sx#rxira#r <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor. ronmental Services z Inc. JkQb NG fZ <br /> Address: 1419 North Ma rcpt Blvd. , Silite 547 <br /> Clty- Sacramento Zip: 95834-0457 <br /> Phone #: <br /> Authorized representative of contractor certifying through signature below that the rank has been decontaminated in an ` <br /> approved manner as required by Cal EPA. <br /> Signature: <br /> Titre: <br /> rsaaaswa>aaxs;wsasssYawaaaaasaaax#Yxsssass#s#awassaaas>asaaaa>aaasaaaasaaaswaias>aas>wsaaa>wi»aaxaas>;axaas <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.- eic 11--5OAJ <br /> Address:_ ;K33 10 Z4 1' Citi Zip: <br /> Phone #: ( CD ) Z3 <br /> T— <br /> mate Tank Received: <br /> Signature: <br /> Titre: <br />•i>Yia#>Y#Yxiii>iiia»ix>falxiYiYaiix#i#iixxi»xwaiiiiiYfa>Yaiaixiiiiiii>isYiiaxi>iiiii#xif YiwiY»ifiYiYixi <br /> H 23 049 (Revised 7-10-92) Page 10 <br />