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UNDERGROUND STORAGE TANS DISPOSITION TRACKING RECORD <br /> fi.u..w„sista,......u.a,saaa..sasaaf>saa.>r»...su.a>aa aa.a.faru.a».sa...>..a>sy aa.>,aaaa a,a.ii..wY} <br /> SECTION 1 - Public Health Services Tracldng 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 /> rev/cling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: DrY1DVIlLob, �OA- AUPsk2 wJpS <br /> FACu P?Y ADDRESS: ZO5I G 9!60'f M11� tom-p(.) LOF�1 ( GQ CISZgO <br /> TAMC ID :39 D r Tank Description: 5000 6kZV-�,t1 (OAC,6 cw,f - 9-/-Selo C, Pl P/Wa <br /> .a.ai...f}.aaf}.}.iaiti.latltl.fit.f titlt,f if if}l.i.,i>tf if tt.aftii..fiiwi..l11111f.1..ltYf lla..tf if l...... <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: SSMC O <br /> Address: (Z1S• 7ff( ST City. IUDIST� Z p: 95 3 SI <br /> Phone m: (ZD5 ) r7- I(b i Date Tank Removed: lZ_ <br /> ,...................t>..f.....t..ti........wa..f.i.....t...,..t.....i...................................... <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor: SCMC 0 <br /> Address: 1217 �. -7fiW �f City 0i)E,510 Zip: �I C77V <br /> Phone #: ( L`7 ) <br /> Authorized represe rive of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved er requ' ed by Cal EPA. <br /> Signature: Title: <br /> .....f...................f..t....,.........,....,.,,.....,.,.,,,...i.......f....i.......................... <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:/ ,/��bES?U. r( 1�11� (OlAs9,4 Y <br /> Address: 1q0-5 / ( r1T J-r City. 4,06c<i7`r0 Zip: OJ)z S, <br /> Phone 70 ) 5 2-7--24,715' - <br /> Date Tank Received: U -/ <br /> signature: x.61 Title: <br /> .....................• a......a.........a.a..........f...........................................,if... <br /> Ell 23 04.9 (Revised 7-10-92) Page 10 <br />