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ENVIRONMENTAL HEALTH DEPAIq&CEVEL <br /> AUG 10 N15 <br /> n5-10,avr,) STORAGE TANK DISPOSITION TRACKING RECOWARONMENTAL <br /> w###w#+ti#titt#i+{itit##tit#itiit#M:#i#w#ttwt##t+tttt##tttt##ttw#ittwi*t#ttww###i#iiii#w";jATuM OI'it#4 <br /> tiii1f <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 30 da of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br /> completed and returned. <br /> >. / �.+ _ - - <br /> FACILITY NAME; IN !G fC <br /> 6 02 �9l7 <br /> FACILITY ADDR�E/SrS: /� <br /> TANK ID �[ •Ij�^ i S O C��� PREVIOUS TANK CONTENTS: <br /> iY###Wt#iiiititi#i#iii##Wt#wWW###wit%#wwi#rt#iiti#ii%i#wiiiiitiii#t#Wt#ii##W#it#iiit#t##i#i##t#tt*itWiiYti%# I <br /> SECTION 2-To be filled out by thank removal coh/tractorr: <br /> Tank Removal Contractor. <br /> � I <br /> Address: <br /> �' QD� 5�� City; �� Zip: <br /> p� L! <br /> Phone#: Date Tank Removed: <br /> tss*#t*t##hitt**tttttttt***wttw*#t*w*tttww*trtttttt*ttyttt#ttt*ti##wtwwwt*w*♦www#tw#tww*wwwwitw###itttt*t* <br /> SECTION 3-To be filled out by contractor "decontaminating hank": <br /> Tank Decontamination Contractor: < %�- •' Q2��- / <br /> Address: / (JO /�6� �i�/ City: G a�J�J Zip: �12 <br /> Phone#: Za 3 Z g Jy 5' �`/ <br /> Authorized representative of contractor certif eingthrough signature below that the tank as be de ontami ted in an approved <br /> manner as required by Cal EPA. <br /> Name:�i�iZT �({P Title: <br /> #rtit#+i#ttt+iti++*tint#WtiWtt#t*Wwitt###t##tttt#iititt#t#itti t *tt w*tMwt it#Wi itti W#iit#it#itti#iii#i <br /> SECTION 4-To be signed and dated by an authorized representative of treatme t store e,or- sposal facility <br /> accepting tank and/or.piping. <br /> Facility Name:. /ZZACd <br /> Address:_ Z /-5� / <br /> � tcity: <br /> © ' <br /> AZip: <br /> Phone <br /> `1'4gi4iC� �af'1§.I.tl,�t;m � � '°, e r vrJo .li'u+-r'xresfldf��J��� <br /> #i+#+{##tYtittt#+ttitttttttiii###{i##t#�4 ###i#itt*ti#i+#iWi#ttii##+i*##tti%ilii#iti#itt#iitrtiit##+#+%tii <br /> EH 23 046 (Revised$/3/07) 10 <br /> i <br />