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JAN 1 1993 <br /> ENVIRONMENTAL HEALrf i <br /> PERMIT/SERVICES <br /> Y <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> !l##tftt#tttt##s#iitii#fftttttit#4ii4ff•ttittt#i44ii4#iffttftttii##sii#ftttttsit##i#ifttttt#t##slRRrtYYRY•Y <br /> F SECTION I - Public Health Services Tracking Sheet wW accompany each tank sired with its site Identification number. <br /> The Tracking Sheet is to be returned to Public Health Services withln 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 /> FACILITYNAME: !er6Z 24c�, & 7c0Z <br /> FACILITY ADDRESS: -So Z 3 / + + /�7L� c: <br /> TANK ID #39 - Tank Description: / <br /> !!►##s#t#F###it#R####4iii#fft#t#ttfttti#i4i#i#tttift#i#t##tttifttti#t#f#t#tittiff#####ttt##r#rr##RtRRR+ rRY <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Zip:�7 S (D <br /> j Phone #: (ZO'� L 3 Date Tank Removed: <br /> i 11W ######+/##tt##tit#i#t##i4ifi#####f#r#ttttt#tfittti#4ti#ti4iit#lilttt#tttttt#tt#•i####t##tirRi#rt##r#•#Y+Y.•Y <br /> i <br /> SECTION 3 - To be filled out by contractor 'decontaminat g tank': <br /> Tank Decontamination Contractor: T� c _..- <br /> Address: City: Td,�L rn (d Zip: 1. - S <br /> Phone #: <br /> Authorized repres ntat vontractor certifying through signature below that the tank has been decontaminated in tin <br /> approved n r r u -by-Cal EPA, <br /> Signature: _ - Ld/ Title:. . �.s <br /> Yr#R#f#rt##•tt*##t##�#4i#####fi#ffffittf fttt#titt44i4444ifi#iii#ift#tf ttttttt#irftt#4#tfi#RRrir!#Y!!#l1�Y+1 <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: L_ <br /> Address: 2 Ltc, V L CittiSit c ctC-T Zip: <br /> Phone #: ZL OC( ) <br /> Date Tank Received: - <br /> Signature: Title: <br /> tt#►#fti#4t•##littitft##ift144#f4ffffftftitt}1444444#t4ffitt#tftf4tytt#if44##t#ft#tttttfFt#r######Rt!!!Y <br /> EH 23 049 (Raviaad 7-10-92) Pay* 10 <br />