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S J ONMENTAL HEALTH D G RECORD UNDERGROL STORAGE TANK DISPOSITION TRa� Sheet shall accompany each tank affixed *...***._.****.**....*_*___*•_.*_______*•_**_#_===='vision Tank Tracking=_**.*:.__••__•_•*_*__#*._.*.Health SECTION 1 - Public Health Services Environmental Health Dc it holder is responsible for site identification number. The Tank Tracking Sheet is to be returned to public Health Services Environmental With its the disposal or recycling facility. The p� Division within 30 days of acceptance of the tank by ensuring that this form is completed and returned. Qv IV— 5-roP M�K� 'tel2 i FACILITY NANfE: GA gS33 FACILITY ADDRESS: I I�C(o Ull, LDt)tSE �'1/� MA -� �O,�ODPREVIOUS TANK CONTE:vTS= VNt.�I'�e� �-s5 TANK ID #39 - 12(— 2 TANK SIZE: - *_******_*******_*_•*« removal contractor: SECTION 2 - To be filled out by tack ��/a� !NC• WA L:rt, 1 E1V Est r� Tank Removal Contractor: City: W. SAC4AMp,2fl Zip: cT Sb� 1 Address: �a �X l o2S Dace Tank Removed: Phone ****_*_*.*_+�***se=******=,ase*..*rs=.*==•*decontaminating*tank *****___*•=*.s.*=•* SECTION 3 - To be filled out by contractor tJ 6, INC. Contractor: Wfl('�^/ �6:'t'- YLt 4 Sb� Tank DecontaminationSAC.76• Zip: city-Ni Address: �D �Ox t•�2� Phone #: ( I�) 3 3` been decontaminated in an approved uthorized representative of contractor certifying through Sigma below that the tank has `� Cal EPA. manner as required by Date � Signature:Title: Name: or disposal facility *.r*+rsss****s=*sus==**=•='a=.s**.s+►.*+s**=ss.ea.**=*to storage,.r=sae,ss=*=•=,r**+rae*ae=a..* _•*********•*_**__**=ed and dated by an authorized representative of the nYaanta SECTION 4 - To be sign accepting tank and/or Piping. C t=5a.�1 Ing C. Facility Name: t City:L1 GH/o'no Zip: Address: 2SS 3 3 Phone #: ( ) Dace Tank Received: Date Signature: Tide• Name: * _.*._.__*=...s+a=•==*=•r`=*s**,.s*==sa.r,a+►..+*r.+t..=*=a'= Page 10 EH 2--, 046 (Revised 7/10/96)