Laserfiche WebLink
UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> iYxxx#!!#ltiYiirxiYi44l R#!!#!ilii!iii#x#x####Mii>YYxrtY#xxf##llrYiii4#44fx!###iiixYYYf!#!»iYiii#44#!!4###### <br /> SECTION L - 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. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID #39 - Tank Description: <br /> #»xiiiix#x##!!!!#a»x Yirtx Y##Y!!t#! »i#tX#»»x##!ar»iiY»xxxirt#»!##tiiirt»x##4f!!xt»i#»ri»xx#Ylxa#»»aiY»x»ixx# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone #: U Date Tank Removed: <br /> »lrtrtrtrr4rtrrtrtrrtlrtrrt»r»ts»»irtf irtYfrrrlrraa»rr»rtf»rrrritrr>tirrirrt!lrrtr»»»rtrtrtrrrrsrr»»rrtfrtrrlatsr»»tY»rtf rtlrt <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #: ( <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 /> aatixiY#xf#lxitxYx4f x#x!!!»i»»iiY4rtxYxrtf 4x:s»»Y»x»#fro!lt:la:aa»YY##x!t»sr»xix#xxa!»iixx#f!!it»xYxYx»Yxxsla <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: <br /> Address: City: Zip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title: <br /> xx##»ii#4##x#r!f##a!!at»»r YY4Y4fx#!##!r!#ora YYirt#xx#aialar!ltasr»!i»fixfx#aaaiiYrtrt#!!#atr»r»»#f lrarlaaa» <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />