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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<br /> SECTION 1 - Public Health Services Tracking Sheet wt11 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. The permit
<br /> holder is responsible for ensuring that this form is completed and returned.
<br /> FACILITY NAME: ✓�c ds� �uGKi lidi /VC,
<br /> FACILITY ADDRESS: �i(O kJeS7 1q r�EuiS 44-0
<br /> TANK iD :39 - �v�-7��0� Tank Description: 13,CC09A-6 ON Dl E5EL-
<br /> SECTION 2 - To be filled out by tanCk�[emoval contractor.
<br /> Tank Removal Contractor:
<br /> Address: 1Ti(3" ��� �/ �7 City. llv)ODEfIU Zip: gS /
<br /> Phone �: t 7i�5 ) SZ� 96 3 Date Tank Removed: '7J' ;-qfq
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<br /> SECTION 3 - To be filled out by contractorecontaminating tank":
<br /> Tank Decontamination Contractor: 5e'410
<br /> Address:—//0/q, 5,, ?rl City: AeZE rQ Zip:
<br /> Phone #: Z( del ) 5-ZY
<br /> Authorized rep entative of contractor certifying through signature below that the tank has been decontaminated in an
<br /> approved as re u' ed by Cal EPA.
<br /> Signature: Title:
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<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:: x/14 C Q
<br /> Address: I x s 2fEZ City. Zip:
<br /> Phone 1-: (
<br /> Date Tank Received:
<br /> Signature: v v Title:
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<br /> EH Z3 049 (Revised 7-10-92) Page 10
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