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SA,YAQUIN COUNTY PUBLIC HEALTH SWICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .aaa.*aaaaaaa.atsaarsaaraaa#aaa##sss*##sss##,t*s*aa#asac�####a##aaa*ssssaas#asses###za#a#s#aaaaaass*#aa.a:ease <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within_30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> crsuring that this form is completed and returned. SAA1RYE- <br /> S t� <br /> FACILITY NAME:`ten--�• lLC-eISTtCS 1��9Et�l�`�� 1�FC�t,Ilt T7icTRtR�s't1 NMOT ERN JQA&IA nl; <br /> FACILITY ADDRESS: 7C6 F P�7T A -;20AN <br /> TANK ID #39 - Y_TANK SIZE:W,OUZ) .,�,2j_PREVIOUS TANK CON LrNTS: tA_N3LEcatar.3-a <br /> d 1. Lq�•O <br /> aaar.taaaaaaas�a����ar#yesossa#aaaraaaaaarr,sa#a#a+rases#aa#a#aa.ease*wa#aa#aa,�a#a.rara,t###aeras#+aaaaaaa,.aaaaaa r <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. C AL I NG <br /> Address: O `-t 0 P F A E�O O Y C�o afl City: Vg C-4,,�2 ll e- Zip: `s Sl <br /> Phone #: (_ ) Date Tank Removed: <br /> aaa#aa.r#eases#aa#r#ar#aaaaaaaaara#a#a##r##aaaraar�r###rraaaaaaaaaaaa#reaper#ease#aaaararaara.a#a#aaaaaaara <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> ank Decontamination Contractor. _ <br /> Address: 3t�+ C��p D , ! c Cen �-��.r — Cis ,.. L,_ •�-Z ' ,i c <br /> Phone ,it: <br /> Authorized representative of contractor certifying through signature below that the tank has be= decontaminated in an approved <br /> manner as rewired by Cal EPA. <br /> Name: —Title: Signature: Date <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> acz.-pting tank and/or piping. <br /> Facility Name: E GT &=.I ot/ <br /> Address: ZS'S" 04 D City: X u-rt n A/Z2 Zip: ?$&/ <br /> Phone #: ( — <br /> Date Tank Re=;.Ved• <br /> Name: Title- Signature: Date <br /> �a#rsaasasaaaaasssserer##sa###r##sssssss###a#ssa#els#ss####sa##a*:serer####*ssassa#ssassassa##saaaaaasa:ass <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />