Laserfiche WebLink
UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> t}tiiiifttiiiii#ttY{ilei!tYiii#iiiikltiifilttYilMltiiftitiiiftiiiY#kttiYiiii#ttiii Yii!!i#tiYif liltiffk#iiliti <br /> SECTION 1 - 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 within 30 days of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: 9; ktc.T dm/e� t� <br /> r-ll nms 46 2. <br /> FACILITY ADDRESS: Crci- n S= >ih I 'tqc+ Wo-�j CA g5QCb-3519 <br /> TANK ID #39 - Tank Description: <br /> t!#ttiiklitt#iktti{t?itiiif i{iiiiikkt»#ikt>i#let#{##tt Yittt{iiltt{kf!# #itliiiif#i!t#Y##!#t#iifl3{k#ktit#i <br /> SECTION 2 - To be filled out by tank removal contractor: /� <br /> Tank Removal Contractor: C-.—, kr mi L S� h=.�"ed�Le-r�4rjc+6c n <br /> Address: P.O. C-)OX 11$5 City: .hiCn Zip: C5q'Q� <br /> Phone #: 8k %CR I IN Date Tank Removed: <br /> itt»>#}#>#fiii#kill{iktf#iiiiiitittii{##!##fi��#i#itif littitit{#itt##itti###tilt#fii{xiititi#iti###ii#iii##fi <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #: ( <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Signature: <br /> Title: <br /> Ytiiktiifi#3{#!i{kltii#if lfif kill#{fk!{ifilY}#fY}till#ti#iii!!Yi#t{k}itiY##iiik#3#k##ii##{k#t#k}ti#iif#ik#t{f <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City' Zip: <br /> Phone #: (� <br /> Date Tank Received: <br /> Title: <br /> Signature: <br /> 3»>fiix{fis»#fixsk:#x»a#let##irk»#itfifit#fit#isfit»ikt#xY#fis{fist#!t{ik»tfits#xtt#fiat#ilei#fins#fi»t#filet#fi{x»#3#fi#t <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />