Laserfiche WebLink
UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> +rssraaaa>assaaasruraasaasxasaaaasaasaaaxaasxaaaaaaaaaasraaaaaaaa aaaxsrssaaaa+aaassaarwasaaasxasaaaaa+x <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: <br /> FACILITY ADDRESS: '7P� <br /> TANK ID #39 - /7i2� 03 Tank Description: 10,000 gallon single wall steel <br /> +aas+wsr+rxasaasaa+sasasassansa+arswa+rsaxawaaawaaasaaaxaraaaa+rwaaawaasa+aaaaaarwrwrwasasrw+xaaaw:aswrsws+ i <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> 1 <br /> Tank Removal Contractor. Advanced Envirorunental Services Inc. <br /> Address: 1419 North Market Blvd. , <br /> Suite S Clty: Sa ram ntn ZIP: <br /> P: <br /> 95834-0457 <br /> Phone #: ( 9T6 ) 92808300 Date Tank Removed: <br /> +w+waassawawawxaawrwaswawawawsawawrraawsawwrwxaaw+r+asasw+wasaewwwawswrwxawswswswswawwsswswaawrara+a++awrww <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank'; <br /> Tank Decontamination Contractor. <br /> cSt 3 �YG�i �,¢C J�alz •, <br /> Addres: 1419 North Market Blvd. Suite 5 <br /> Cit3"-za.Q*a-mento zip:,, 95834_0457 <br /> Phone #: 916 928-8300 <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: <br /> Title- <br /> wwaaarsaswarsasasaaassarsr+assaaa:aasasrsasrsrsawassasrsaraaaara+aasxa+ssrwrwsrsrasaaaararasarxaa*asawwxsaa <br /> SECTION 4 - be signed and dated by ping.as <br /> acceptingtank <br /> authorized representative of the treatment,storage, or disposal facility <br /> accepting and/or piping. <br /> Facility Name: �/c C�5 d A <br /> Address: f6 City�Zi : 9 �/ <br /> Phone #; (�� Z3S��3P3 P <br /> Date Tank Received: <br />':.Ignarure• <br /> Title: <br /> v+w+awswaw+wawwaassaasasasasaaasx+xawxawaaswa+aaxss+aaaaawssaaararrsasaasaaaaaaasasrw+aaaawx+srwwaa++aw♦ <br />'t1 23 049 [Revised 7-10-92) <br /> Page 10 <br />