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0 0 <br />'UNDERGROUND STORAGE TANK DLSPOSITION TRACMG RECORD <br />.......a•u•aaaa•Iaaa•a„•aruY•,arrrlr••aa1•aaa,arae,rrr••••arr/•r,aaaa/rr•••a•, •.aa•,rara•Iua•.,aaaa,a• <br />SECTION t - Public Health Services Tracking Sheet will accompany each tank affixed with its site Identification number. <br />The Tracking Sheet Is to be returned to Public Health Services yvithlu 30 dare Of acceptance of the tank by the disposal or <br />recyelWS facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACIIdTY NAME - E <br />FACUN ADDRESS: 2 "XI 5 <br />TANK fD #39.148 2 - D L� Tank <br />......••a•reface••aa••a•a•aa1,•aaau,aaaa.l•aaaa•r•.•••saw•aaaa•,raaa„ra•aa1••a•rrrl•rrra a,••aaal,ru sal•• <br />SM—nON 2 • TO be filled out bythitlt rkmoyglcontractor; <br />Tank Removal Contractor {� <br />Address:_ 3151x3 A V F_ I {V1anF�"- City; '+ 7A p: 3iO✓8 <br />Phone: �� l?(O I—'% 11 Uate Task Remo <br />....uCi•,,,,,•r•/,r•,aaa•Ice•aaa,•,a•aaa.•••aaa,.••rrraa•.,aaal..a•r,r,1.aa•a♦a••,rraa•,,,aa•a••,ru.••a,aa• <br />SEC[MON 3 • To be filled out by contractorn1�_•d ntaminadng tank: <br />Tank Decontamination Contractor. FH111 <br />Addreu:_ 3City: <br />Authorized representative or contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner as required by Cal EPA <br />Tido: E6` .` <br />rH HHHNaV•Hra,1Up•aM•rttral•HraH••aHa111NlrHN•apHHa••a•a N111MH11Har1 •aNHaHaalalU H• <br />SECTION 4 - To be signed and dated by an authorized rEpreaentadre of the treatment, Storage, or disposal facility <br />atxxpting tank and/or piping. <br />Faculty Name: a LA, A M U(C" <br />Address:_ ) 1 Cj (0))/kms 1 City._ Zip: <br />!•••!•YY!!•!!N!lslNNu•ln •a•p Y•r rrMaarca•Yl,rr!!!•,•!•aaaY••rr••!••aa•r rl1,•1•nUpa•••a••a,•r!,• <br />EN 23 049 (Reviled 7.10-92) Pea* 10 <br />