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SAN J4WUl NC PUBLIC HEALTH SER& <br /> ENVIROAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sbeet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. r <br /> FACILITY NAME: -S OC-C`' 1y\ � lel f° DLS�C4— _ <br /> FACILITY ADDRESS: ? i My4k—; <br /> TANK ID #39 - ✓'E' TANK SIZE:/P/ OV <br /> 0 PREVIOUS TANK CONTENTS: <br /> ++*w+x**++++,�**+rrt,�w*+r#*rt++**+*rtr,►*rtrt**w+****+»r++s++**s++*++++# ****++++*+***+r+r**r+***r.*+**+s»,►*+*+rt <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ /�,OT - ez�=b -1(,1,2,Unn��iy <br /> Address. gbM MJJ f. City: <269� Zip: <br /> Phone #: (Sl� } q67 ft(a Date Tank Removed: W`7-' <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: I'y? <br /> ddress: • K) I C,1I City: 5/7CVJZ.li'1 Zip: <br /> Phone #: COZ /&7 AQ <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. p <br /> Name: 11�' J � Title: r Signature <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: 71J <br /> t-- <br /> Address: City: Zip: <br /> Phone #: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ++►+�**++++r+►*+r+***+rtrt**+++.**rtrt***rt:*++w+*++*+**.+s+rs*+**+***+***+**+++smart++**++++++++++++**+***+++*+wwrtrt <br /> H 23 046 (Revised 10119198) Page 10 <br />