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UNDERGROUND STORAGE TANK DISPOSITION TRACICIN RECORD <br /> Wass*****W*** <br /> 4.tel#stLai#4/s■##iteasi#ttitai4itaiaL#Sisal <br /> SECTION f - 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 dais of acceptance of the tank by the disposal or <br /> recycling facility. The permit molder is responsible for ensuring that this form is completed and ret=ed- <br /> FACILITY NAME: <br /> FACILITY ADDRESS: O W65.7 L <br /> TANK ID #39 - _ Z2]a fl z_ <br /> Tank De'criptiau: 2S cYI�'� e! 03Srr/aL <br /> ei■i/ai#Lara■ateti•tiaii#t til#iliisa 41stiesii#atre■ri■iRRRSRRsafiiiia!■ia.aRaRits4#ilLeiait aai44si■■■#i sR■i <br /> SEC'T'ION 2 -To be filled out by tank removal contractor' <br /> Tank Removal Contractor: 1-1 '�. d,1� E� <br /> Zip: <br /> Address: M6.1 <br /> G(, u/ ►¢ , City AG y s3 7� <br /> Phone # Date Tank Removed: <br /> i Raai■ttrifili►tial teal■i rail#aaLii#.tai#aseai■#ilea#4■LsiRiae i#i/ssRilLi#ai■a#•ii ai■it r■#La slat•L#i lss#its <br /> SECTION 3 -To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: I�fG/ � LL�, �1 I� - City: Zip: 7`S <br /> Phone #: {� ' <br /> Authorized representative of contractor certifying through signature below that the tank has ee�T ���E�L <br /> an <br /> approved manner as reqt' ed by Cal EPA. <br /> Signature: ��ith/~-Q`� Z1� Title: IDI 9� <br /> t� <br /> allies■##iiatra■#4Ltai#lltlaa tilt• iiaa4#as ai###fr##ttreaf/tssi#tlrr#t11s#4.e sa#tra iattr■#i!■i.ri Lasa#arez <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal fatality <br /> accepting tank and/or piping. <br /> Fatality Name: T/Z ZAAJ <br /> S L( – City 5G,P.4HKF-�-/ �—Zp: <br /> Address' SZ SZ h <br /> Phone #: �!Z <br /> Date Tank R <br /> ,d <br /> Title• LrM� `� <br /> Signat <br /> v iliti#iiteil##is ae#i#L/tiR1i1#4ii#i■•Ria#asais■.aa■iii L■#a it Rzlszziles#Ra;■ia►■#ass##taiaia ilf all#aasa#■ <br /> EH 23 049 [Revised 7.10-92] Page 10 <br />