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UNDERGROUND STORAGE TANK DISPOSITION TIZACKING RECORD <br /> .....•.,•.•.••.....•...«««««...••««.....................«...................•«..,..««.•......•...•......•.. <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 IIcalth 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: i/�T Z % CO �/ %✓� ��� C <br /> FACILITY ADDRESS: 1// C %O/2 /2 , <br /> TANK ID #39 - Tank Description: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: S7-0C L 721,-f P'/ C <br /> Address: ^r U '-// 6� City: ;S3-7C"k/ Zip: <br /> Phone #: ( L o 5 ) yr- Dnte Tank Removed: <br /> SECTION1 - To be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor: S'T=9C !c Td S'Ei2 t// C STIP L- Q L"I ee. <br /> ddress: zO city: S7-�—A/ zip: !"Is <br /> Phone #: ( <br /> AuthorJig ntractor certifying through signature below that the tank has been decontaminated in an <br /> approvs b Cal EP) .Signatu <br /> SEC1'I0N 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: C'+( 015fiS �7- --�/Z-- G <br /> address: /<S'elcD O t7 city: ;(/iZ ca C zip: s' t� <br /> Phone #: <br /> Dale Tank Rece' �� ✓l `J <br /> i <br /> Signature: _ Title: <br /> .,...... . ..«. .,•.•.«........... ...«........................................................•........ <br /> '� 23 049 (Re ,leed 7-10-92) Pea. 10 <br />