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SA1V*dAQUIN COUNTY PUBLIC HEALTH Sb.-VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rrti►fi;ir+riirt*rtis+irt+#►t++#*rtt►i**+rw*i+*+*iiiw*ri*sw*ii*+**t*ir►++}rt+**rtf►rtfi►rtirr*+r+*r*►s*siis+i►rr}ii <br /> SECTION 1- Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany eack tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: -�l4 na Q Lt✓x' 5411/' S c. <br /> FACILITY ADDRESS: IJI-45 J) (J/1 S <br /> TANK ID#39- TANK SIZE: /0,DDD PREVIOUS TANK CONTENTS: A f/ aP Jt,,d <br /> *i►r►t*}+«tri►i*r#srit►tat*►►►«ti*#4t##►►r#►►#r►ii►#►iit;i*t•►r►►irt►*#i**►*#►i*#►i►trt#t*rri#iitiY}#ir###tri <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal <br /> Contractor. /�4 s �co,R)i n P 5UC. 1-nL // _ <br /> Address: ti5h�0 � 6-EreP� City: L5 Zip: ?3&35- <br /> Phone#: Date Tank Removed: <br /> wrr#srsrrts#*shitsiii*itri##i#►t*ii+i:#rtw+iwsrtwrtr##t++rtr*tti+st+rtrtt*r}i#ti*#►+rt#irt#rt#t►rt*srtis#rtritts##ssiss <br /> SECTION 3-To be filled out by contractor "``decontaminating tank": <br /> Tank Decontamination Contractor:�-/5 a-s J fQP�t at nuc Tn c <br /> Address: JV0 et City: 46 6Ql--ICIs Zip. 3 35 <br /> Phone#: ( X09 ) Rc) 1,5'`,70 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> ►►rrrt►►sr►rrrrrrrrrrr+rrrrrr++ra►+rtr*rwwrttri►►wt}rrt►rrt►rt#r►ttt+t*4#►#*t#rt+t*#*t**irirti►*tt►#trtt►rtrtrrrt <br /> SECTION 4-To be signed and dared 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 /> Name: Title: Signature: Date <br /> i##t*##t+#t*i*it*}+itiiitii}*#fit##}}►}ti}#►i#r#iit#it#t►iy+i*it►►Y►iiiis►Y44rtitrtr►ititr#+*#++####rtrtrt###+ <br /> EH 23 046 (Revised 08/13199) Page 10 <br />