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• <br />93 DEC -3 PH 2: 19 <br />UNDERCROUND STORAGE TANK DISPOSITION 'CRACKING RECORD <br />•.r••r••••••n•••••••r••u••••••••••••.•.•r••••••••••••rr•••••«••„r•••r••••rrr•r•••••,•••••••••q••ur•••• <br />SEMON L - Public Health Services Tracking Sheet will aacotn n each tank <br />The Tracking Sheet Is to be returned to Public Health Servioea nth n vt tan afted with Its site Identi&nUon number, <br />recycling Wilily. The Permit holder Is rcaponst'ble For ensuring that�thjs=Io� is acceptance <br />and returned by the disposal or <br />FACfI:lTy NAME - 7 G r-0, I L � 1 _ Gr <br />FACRZry ADDRESS, 'Z 7p . t5(Q <br />TANK fD *39 - crz, . ,Conic <br />DescrtpUoa;_ <br />SECTION 1 • To be filled out by �n� <br />Tank Removal Contmm .. d� r o val contractor, <br />City - A --0F zip, <br />Phone N: �� V (O • 2071 I _ <br />Date Task Removed: It S <br />SECTION 3 • To be filled out by contractdemata <br />Tank Decontamination .Ceatr..N,. g.•❑ _ —, nlusting tank'r <br />31 s63 A 06. q <br />Phone it: <br />Clty:P—ACxj Zip; 9 3%38 <br />Authorized tepteaeatative of aontrector certifying through signature be, that the tank has been decontaminated in ea <br />approved manner as required by Cal EPA <br />X <br />Title: A G �� <br />SECTION 4 - Ac be signed and dated <br />Accepting by an authorized "Presentative of the vestment, storage, or disposal facility <br />xpting tank and/or piping. <br />Facility <br />Phone tl <br />Date Tank <br />UI(N <br />I Sb3 L±ti p ` -536 <br />�_ CI <br />)�(P I 2 I C) JZ. �,P. <br />;;5-9 <br />— Title: <br />IN 23 049 (Revised 7.10.92) <br />Pape 10 <br />