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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> !!lttrrtt+tt+irs#4irttst!l444++:++++rrrrssstiR#++rr44###+iirrrrr++•RRRRRRR44RR#+rrrittrsrtt+iiRRsisRt#++++ts <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. 'Me permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: JPA()y2 c.F �l�-rrn <br /> FACILITY ADDRESS: /-/og54E '/ 'A <br /> TANK ID #39 - Tank Description: — 9 Z9 64ano'] W&'v� <br /> #kkt}}#####ii+Y1tr44rt W4444k R++Y}}+}}sWWWW#}##t+ttt!11444t44iitltirrl4}rrrrWW4rt##YYttktittlt!!lkklk#}#!###F# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:S-'Tc_ '_ ani SQM- �T+4-�y.� �'/�.�C - +r-CSG• <br /> Address: O Zo AL- L"'O 1 � City_6 ' Zip: <br /> Phone #: ( Date Tank Removed: <br /> • ii##rtrtrt#####4#tRlWkk#########Rrt4##44kik+#44###4####ti WW4rt4W###4#4##4Mrii4tii Rt++iiirit+i++iti#RRiRR#444!4#Y <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: 4rcz� <br /> Address: RZD 2,16- lldlad 5(, City:4 Zip: 5�s``Ze( <br /> Phone #: (ZOC1 ) Z144--LM <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: Title: <br /> #####fififikli WW Wkkk#R#4RRiif[rl Rrfi W44krtW###4###RtiRlWikkkk#s#4####R#irt4rt4Ri4k4+RBBB#########44riiY4tiiit#4+## <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: � $I� C_� IST M�r <br /> Address: c'106 / O�/ GouT,e <br /> t/ City: LBG�-- Zip: <br /> Phone #: (2-W ) 6 6 - IZ-79 <br /> Date Tank Received: <br /> •Signature: Title: <br /> #fifitRtk##rt#4###4tfi4#k Rkkrtti#4rt4#4#444#4##R##R##4#444t4rtti Rt RR###RBBB#tt#4tttttt44tktk Ytrtk+i#RRR#R##### <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />