Laserfiche WebLink
t <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The'T'racking.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 holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME:/ C® y4 2 <br /> FACILITY ADDRESS: / 2 z a '-'Z/ LUe ®` r r.r2 tj <br /> TANK ID #39 - Tank Description: <br /> SECTION 2 - To be filled ouC t b tank removal copctor. <br /> Tank Removal Contractor. :rZ" <br /> Address: GC./® 1 ta0=a re GJ12 City- <br /> - '� �C�ra Zip: 5 Z <br /> Phone #: 3G. Date Tank Removed: -7 -- 1 - `? <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: cr Zip: <br /> Phone #: Z Z — ZGo Z SS <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Signature: Title: <br /> SECTION 4 - To be signed and dated by an.authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. , <br /> Facility Name: G''a <br /> Address: '-T'Z 6LIE City: Zip: <br /> Phone #: 2 t - t ct �! <br /> Date Tank Rece' <br /> n <br /> Signatu Title: / <br /> EN 23 049 (Revised 7-10-92) Page 10 <br />