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.y SAr, A.QUIN COUN'T'Y PUBLIC IIEAL'I'11 SE. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND S'T'ORAGE TANK DISPOSI'T'ION TRACKING RECORD <br /> SECTION t Public Ilealth Services Environmental health Division Tank Tracking Sheet shall accompany eacW6nk affixed with <br /> its site identification number. "The 'Tank Tracking Sheet is to be returned to Public Elealth 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. <br /> FACILITY NAME:-W--0A.1- <br /> FACILITY ADDRESS:_ O3- <br /> d! <br /> TANK ID 1139 - TANK SIZE: LAQ _PREVIOUS 'TANK CONTENTS: <br /> :MC-1101114 2 - To be iiiied out by tank Iciltoval cvtntractor: <br /> Tank Removal Contractor: Z T�(���, �� d L�S�. <br /> Address: City:__1��f/`t., Zip: � <br /> Phone11: (�,C3`�? ) �g3t _ Date Tank Removed: -��-(A-CA— <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> I ank Decontamination Contractor: --------- <br /> Address: ����k-�� tl/.�I----- _ ------- CitY:jA--vv#1AJLf/_ Lip: TJ t!�12 <br /> Phone a: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in in approved <br /> manner eyuired by Cal EPA. <br /> Name: Title: Signature:-AL4 4 tzd tom, _Date IL 1$-9fi. _ <br /> SFS C7JON d - To he Opned a.nd Mated by an niitberized reprf--srntative of the treatment, storage. or disposal facility <br /> accepting tan71-- <br /> /or piping. <br /> Facility Name:__�_j^f cLti( —t C <br /> u� _ Q e�� <br /> Address: _--5 Of 01 4/�. ^City:�Q(�rQ tWeof O Zip:1,3-9 2 <br /> phone b: (`7 <br /> Datc "Tank Received: _f - / 9912 <br /> T lame: ,[�R Nr �jr®��f_Title: f �G� Si 4 ate " �9 / <br /> *#d,*+*#*�•***#+r:k.�*y,#+d-#k#++k#++k+++##+#+k*w#*+,k**#####*+###++##*+*+*#+k+*#*+##+*++++k#++##R*+M++�++#+k*+++* <br /> Ell 23 046 (Revised 10/19198) Page 10 <br />