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ENVIRONMENTAL HEALTH DEPARfkr y CL <br /> AUG .1 Q 2015 <br /> /}BO✓Efi2oJi✓J STORAGE TANK DISPOSITIONTRACKINGRECOi5NVpI�RONMENTAL <br /> *14C 'rWrW0 i0+T4 i+tT . <br /> SECTION 1 - Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 36 days of <br /> acceptance of the tank by the disposal or recycling facility, The permit holder ii responsible for ensuring that this form is <br /> completed and returned.. j <br /> FACIL&NAME: 1/IJ_ /£/t S'7<F7/S� 7(/ K C 7f 2 <br /> FACILITY ADDRESS` sZs i9Nt /cJ� SYor7�1 Com/ 9S^Lo� <br /> TANK ID+r 5 DD ��L/f3.�� � PREVIOUS TANK CONTENTS: Cl /( <br /> a#ir#ttat#tiirrttrrr##trtr+rtrt+irt+wWirtWW+#+Wrtrti WW##+#ii+Ww#rt#W#wWi#WWWWW##WWrt#WW+#W#W+WwW##WWyi#WWW#WW#####*WW# <br /> SECTION 2-To be filled out by tank removal cohtractor: <br /> Tank Removal Contractor: <J //� 77/nu�c- 2,Z/ <br /> Address: /" -'o 6L r 35 7 <br /> - --- city: Zoe/ zip: %S'L 74-/ i <br /> G� <br /> Phone#:(7s4�) 3 �9 ,j 7 �� Date TankRemoved:_ <br /> wrew########y##w*####w#*#WwwwwWwwWw*ww#wwwWwwtwwwwwwW#wtw#w**wwwwtwwWwwWwW+wwvwWWWWw#wWwwwwwwwtwwwwWw#wWwW# - <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: c <br /> Address: ® L�4 �n j2 <br /> city: zip:, <br /> Phone#: ZO _132 g <br /> Authorized representative of contractorcerti6drig through signature below that the tank deontami ated in an approved <br /> manner as required by Cal EPA. <br /> Name:e ? ((p�Title: Fcy 7,c t a8 <br /> SECTION 4-To be signed and dated by an authorized representative of treatme t stor e,or sposal facility <br /> accepting tank and/or piping. 9 <br /> Facility Name:_ .1 /eaN 4 <br /> Address: _ f®O �S/r /t%/9/l t✓ i�/A2/t/� City: /!r'G�/On� Zip: <br /> Phone#:(/) 3� / © ! <br /> 1c �� p nn. <br /> �' .,�e+a,-�, rxl►Tv Ct7 l�N�t` i'gi'(7i;eis.A�+�.-Yoe/.o � .,d.ra __aaa� !t�%!�- <br /> EH 23 046 (Revised$/3/07) 10 <br /> i <br />