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U <br /> XX1UTNr'rDnEE3RGROUND STORAGE TANK DISPOSITION 'TRACKING RECORD <br /> raarrrssrsalssa+treat*asssaasrrrrsa*a■arrlrrrrrrsrr*s►sasrssrr*ararsars*r:ra+*as*err*rrrasarrarr*rasars*sea <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its Site Identification cumber. <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 bolder is responsible for ensuring that this form is completed and retumed. <br /> FACILITY NAME:— <br /> W t T� T,Q,4Cc <br /> FACILITY ADDRESS: D W T , ANf T2.gG 7� <br /> TANK M #39 - Z 0 '' <br /> Tank Description: c ! �ti S/ <br /> aaa**r!****aaso**we arse•f saw saw■*r*rr*a t+raeaa*+ea*Iasi■■aaaiaaaaf int ossa►cos stain r+r*1aalar*rr*r*e!*►frit <br /> SECTION 2 - To be fined out by tank removal contractor- <br /> 91, <br /> ontractor• �Z d1 Cf S yG <br /> TankRemovalContractor <br /> Address: G C ►� City AG Zip: -qs7 z. <br /> Phone #: ( 7n4 ) � �7 5�-- <br /> Date Tank Removed: Z <br /> s*cast*s*esaarserrarsaesrsaaaasa+r*liaarr+sr*ssae*►r <br /> ass aatr■i***rsssaraa*r*sea rs•arrarassarae**raarar*r**sr <br /> SECTION 3 - To be filled out by contractor 'decontaminating taak': _ <br /> Tank Decontamination Contractor: RX6 ,47- <br /> LL <br /> Address: ISG l 'f <br /> City Zip: 7/ <br /> Phone #: t� <br /> Authorized representative of contractor ce g through signature below that the tank hasted in an <br /> h Sir m� � <br /> approved manner assrrequired by Cal EPA. <br /> Signature: `7 '1��it `� •. Title: 10128 9 <br /> ria areaarrat*r to*larraa arraati*iiia* *r is s as a asa*a4as ara*a as a s 0 a*a a r as f sraasr**tars raaiar**as rR+aia1lirais <br /> SECTION 4 -To be signed and dated by an authorized mpreseutative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: �2 LyQAtJ G'L - O F S�1Crcr�i <br /> Address. <br /> 35 z 6-2 ^ - cozy: �,� Zip: <br /> Phone #: ( VL) I-f z/ — <br /> Date Tank Re=' I) - '73 <br /> Si at Title: <br /> v <br /> r <br /> r*a**rrsass**+lssar**s*ra+sastr*as ssrsasssassraasaissa*asaaa0sraaasaw**ai:*+ria*era*tris**ss*+attar+a++ <br /> EH 23 049 (Revised 7-10-42) Paye 10 <br />