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<br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<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: �o�eT0Oil KDA 4PPGAtuyDS
<br /> FACILITY ADDRESS: Z`rSS I l; �(bµ'f kU(t RO t"t q5-2yo
<br /> TANK M #39 - t6S tSSB–o7 Taak Description: $000 6A Z&,j 6kc,60AG- 71 SSoL, {71PlAfe'
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<br /> SECTION 2 - To be filled out by tank removal contractor.
<br /> Tank Removal Contractor: S6MC O
<br /> Address: /y 7 S• ?h(d ST, City: Zip: 95 3 �-j
<br /> Phone #: (�5 ) rZy��6S3 Date Tank Removed:
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<br /> SECTION 3 - To be filled out by contractor "decontaminating tank":
<br /> Tank Decontamination Contractor: St MCO
<br /> Address: /217 >• 16 City. O �Yc� zip:
<br /> Phone �: ( 2�`7 ) �z`/ X5 a
<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-
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<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/'nk� —
<br /> Address: lkl(o AAI(oELC) b A`/ City. �bl�eS' o zip: 50!51
<br /> Phone �: (2DI S X7'7-76
<br /> Date Tank Received:
<br /> signature: Tide:
<br /> ........aa..............................................................................................
<br /> E9 23 049 (Revised 7-10-92) Page 10
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