|
UNDERGROUND STORAGE TANK DISPOSITION TRACIGNG RECORD
<br />t..>.,,.Y,.ttww>.!f>w.r.l.r+.t.ft,.lt.»laf...tr,.ft.lr.*.,.rlfrtf,+•r••"•>with its site identification number.
<br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed
<br />'l he Tracking Sheet is to be
<br />holder reto Public
<br />blosible fore ensuring thatin 30 of acceptance of the tank this form (s completed and returnedby the disposal or
<br />recycling facility. The pe po g
<br />FACILITY NAME:
<br />FACILITY ADDRESS: -..-2
<br />q tion:
<br />TANK ID #39 - SCt.`7.,/� Tank Description: -
<br />SECTION
<br />"wt wt>tfttu rf r, taf,r rs tf wYa wtf if taf tr,Y!♦awtalf,Y tr a, strt Hlfltrw?>a!r>Ngtf rt1Rl Y>,lft„f >!,l Y,t Y>alttrrt
<br />SECTION 2 - To be filled out by tank removal contractor: Lib"^ E�ccc �10 h
<br />Tank Removal Contractor:
<br />-A 1 C_C(q: i �—zip: Q U
<br />Address: (O H( ) '
<br />Phone #:(
<br />r -, Date Tank Removed:_ /R /lS,
<br />•wHt"rtr Ntwrwr>rtf>wtrYNf>r>flf Htlf Ylwrwlf>rrf»>fwlar,rarr»4w wliR r>rf,!>wf r>ar, rf t>w!>tflrf rY.rr4»,tr
<br />SECTION 3 - To be filled out by contractor "decontaminating tank":
<br />Tank Decontamination Contractor: e
<br />"ti . � e_�lc���• t_ w. l3" K(Q City: L o�� i Zip: q s 1 H!')
<br />S
<br />Address: I Q "D s
<br />Phone #: CDCL) -zx-1-I 3
<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 />_Title: OLA-*)Wf1C—'
<br />Signature:_— \�
<br />rwfrlft>Yrtr+r,tftl,Y,Yf,rrfrff>rrraar,l,rlrrYf!ltwfrflt,rrafrr,rlflrsrrl,rft,,,f rrlrtlf!l,+frl,larrf+f,rff
<br />tment, storage, or disposal facility
<br />SECTION 4 - To be signed and dated by an authorized representative of the trea
<br />accepting tank and/or piping.
<br />Facility Name: - -”
<br />Address:
<br />city. CaW �� Zip: a KEGS--
<br />Phone #: ( SICU) ' A-1
<br />Date Tank Receives:
<br />Title:
<br />re: at
<br />Signut"
<br />igntre: wf ,•>1t,t,tfiftrrrff>fllrt,rr,la>flrflM1rlr„lfRr,lrltrrflttfl4.f rtla?lrraYra,trr,ttftlr♦
<br />EH 23 049 (Revised 7.1(1-92)
<br />Page to
<br />
|