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'.i <br /> UNDERGROUND S'T'ORAGE TANK llTSPOSITiON TRACKING RECORD <br /> }#tf#ff#}}##}}#}lift##tlffi#######4ffti};}}f#tlfiliffffli##l#f4!!ftlffff#itltff###fffffifi##}!##ifilillii#t <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 M dayl of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for enstiring that this form is completed and returned. <br /> FACILI'T'Y NAME: ` A&jc, Ate,� <br /> FACILITY ADDRESS: Y7 ��' r �. JI/_ � / . . <br /> TANK ID #39 . 1< �' 4 Tank Description-L LO,060 A C,l_rx.J <br /> !#!t#ffi#ilft##}}i!lfifft!!l}l!4!!ttlfffifff}}#ltff##fff#iffflff!####f##tft#!#fflff}}##}illi#i###i##i#iii## <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor <br /> E2Q C,- <br /> Address: '3;-70 k(I2 C&L� � City.��Ij Zip: <br /> Phone #: l?. �1 � Date Tank Removed: <br /> f tft#ftlifif#ffi}iii#fifftfllii•t•fffflfff#ii!l4tilffiffffit#ififf}}}}♦flliffliiitliiii#iiiiii#ii#i##t!#iii . <br /> SECTION 3 - To be filled out by contractor Odecontatn ting tank": <br /> 'rank Decontamination Coniracto • .Vit.E' c, <br /> Address: ?ZD 1A 110.3 _ City: Zip: QS" S- <br /> Phone #: LZO <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an i <br /> approved manner as required by Cal EPA. <br /> Signature: Title: <br /> tlfilifflt#}#ll}i!!f#ifftfllii##ffi##fff#lift##tfffff lti}}####!#iflftltitt#ttii#tfiffffffffflf##iii#i!ilii# <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:CAC- r-ptq 7_ 111X4 ' el, <br /> r <br /> Address: c)t'JC� City: "/rTrDC - _ Zip: <br /> Phone #: C20T) ?3.82— - --- <br /> Date Tank Received: <br /> Signature: Title: <br /> #}#}#};•4tiiii!#fff}f#ii!!!tf}f#tfii#if###!tt#�fff#i#iii}lilt!!t#lttitt#itfttRittiiiiili##lfiiff#i#ii### <br /> EH 23 049 (Ravised 7-10-92) Pape 10 <br />