COMPLIANCE INFO_1985-1993 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD iiRf•tffiRRStfftfi*i#ffii*kk#R#ffirfi«#tttffitffiftffititf#t#tttRt«iffitf#tffitft#!$ttR#tf RRltffi*ii;ltttt;*aEttttRa«at*tattf SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site Identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: pG1 C; �t C E e t t (u E -D q -% 1 -_" 113 FACILITY ADDRESS: ME iwiT So (A UIrn S&r( aock ion TANK ID #39 - Tank Description: ;�&OOO --�Ql 10A S fret i�w *itissffi*sissssss.sk*k;;«*s*ai:;;isf#sk«tssfRs#Ret-btsssttslR#tsetses«t$t#siR#R«s#sss#Ret*eft##ri*s*#tssssst SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: A rn n �X r%t- n u t nre�r 1 /tH I n C Address: J It: C,�: rnEc- f Ce, J City:aC(dj'rNC1'L zip: Phone #: (y (6 ) 3g'- b ®U Date Tank Removed: ttRRttttttttfktit«•!tilk#•ti;tffifffitttffittttltRtlftR!«tlttRRtR#tttttt••RltlRtRtR#kffiitt«ffiffi#ttffiftRtltit;ffifftffi*tt SECTION 3 - To be filled out by contractor "d taminating tank"- Tank Decontamination Contractor: � d1 n I Enurron,rien_4 ( �eru[i e S Address: li (315 L•a�6sl- D( -Luc City: zip: Phone #:S( d )_ 222-7910 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA Signature: Title: SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility N j )• Phone #: (AL-)_____ Z-13T� Date Tank Received: Signature: Title: *s*t**affiffiris*s!*sees#sass***arak***sae*s*ser«sk*a*fsstss****ass*sear******s#*sea*;*as*see****asses*asses EH 23 049 (Revised 7-10-92) Page 10