|
UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
<br /> •aaaawa.araaarssr,,,,rasa+„asrr„ ,.,aa.rr.asas♦aria+•arasaa,asst+asaaaa,r,asaar+aasasaa»aaaarr,r.aar,r+.r
<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
<br /> (p'ermit holder is responsible for ensuring that this form is completed and returned.
<br /> FACIIITYNAIME�1OC D�1D& 4A- 44p6"w”
<br /> FACILITY ADDRESS: ZFSS I C164.f i iu( '96 . tool g5-zgo
<br /> TANK D) #39 - (SSR-CA 1 Tank Description: 5000 6A-VI-I/J (p'A.SO L(AG� If Ae O C, PI PI fC,
<br /> ....r.aass..•twaass................ ra„arta.a,••a,a»•aa,w,•asaaaaawaa„araaa.aaasaasa,ra•rrw.,.......+a.
<br /> SECTION 2 - To be filled out by tank removal contractor.
<br /> Tank Removal Contractor: CSr✓M L d
<br /> Address: (Z1"7 S, ?HY Jr, City Mo, STv zip: 95351
<br /> Phone #: (Z05 ) -V2y'1653 Date Tank Removed:
<br /> r.a>..aaarasa.aawaaaw,aawwa•asausa•a„•s�a�,,s�a�,sa,,,aas,a.sats,as,asaa.a.a•a.ar...........a.........a...
<br /> SECTION 3 -To be filled out by contractor "decontaminating tank”:
<br /> Tank DecontaminationL
<br /> tiContractor: EW-0
<br /> Address: /217 >, lr( S-f City: Zip: 1�zi��
<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: Title
<br /> ♦r..,r+was,ata,uw+sat.saasa.aa,,,aasaaaaa„•tarts,rasaaraa»assassraaaa+sat„+asa„aaa,,,aww,ura.a.asa,w.
<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: A- Y S ME f A”
<br /> Address: l/,/6 V N6ELD'`l tlA city: 1�b� VC) zip: rig 3 s l
<br /> Phone #: ( ZDG ) 537 IL2
<br /> Date Tank Received:
<br /> Signature- Title:
<br /> .................ay u,stat,...a.r..........................a.....a...............a.....................
<br /> ER 23 G49 (Revised 7-10-92) Page 10
<br />
|