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UNDERGROUND STORAGE TANK DISPOSI'T'ION 'TRACKING RECOP.I) <br /> r•...r«r•r••••••r••rr•r••r•••••••••u•••r•••r•••r••••••••••r••r••r••r••••••••••••••••rr••••r••••r••••r••••• <br /> SEC1'10N I - 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: <br /> FACILITY ADDRESS: / �/� <br /> TANK ID #39 - I G lf —b ( Tank Description:j-2552>irtALtd cY 6)WVL& OIC, pjq <br /> ••rr•••••rrrrrr•rr•r•rrr••r•r••r••rr••••••r•••r•urr•rr•rrrr•rrrrrrr•••••r•••••••r•.•••••rrr•r•••rrrr••••••• <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor:�j,-L ciQ ��i�/tc� �t7tT�exi �L t o c <br /> Address: a 240 3t� �� City:=&Mc-lC.�A✓ Zip: qC• 5L <br /> Phone #: (V4 1 46V1-9333 Date Tank Removed: <br /> ••••••••rr•rrrr rrrr•rrrr.••r r•r•r••rrr•••••r•r••u•••r••r••••r•••••••r•••••••rr•••••••••r••r••••rrr•••••••• <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> ik Decontamination Contractor. -���y) <br /> ddress: /l/O_ a'aitgR/ 5r City:-5rve E yvN Zip: 'F�, l q <br /> Phone #: ( ) �tj 4t-k333 <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••r•••rr•r•r•••rrrr•r rrr•rr•••••••r•rr•♦r•••••r•rrr•••••••••«r•r••r•r•••.....•......... ' <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: . c , _ <br /> Address: i _ '� LVD CitY:` rL1�g Zip: <br /> Phone #:ISlb, <br /> Date Tank Received: <br /> Signature: Title: <br /> rr••r••••••u•••rr•rrr r•r•••••••••r•r♦rr••••rrr••r••rrur••••r•r•r••••••••••••••••rrr•r••rr••rr•r••r••r• <br /> ti, 23 049 (Revised 7.10-92) Pape 10 <br />