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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> •itttitttttttttpsi♦rttasartisatrtistttr•••••tiauttriststtttittt••rs•ratttsrawttttiiittttautttsrtiti>itti <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracldng 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: -FN E 61 T y OP- T2AG <br /> FACILITY ADDRESS: p�"I QI E S T /I �- S Mi( T 7-g/4,G t/ C/A –7 <br /> , 9 5�3 � ,!,, <br /> TANK ID #39 - 0 —� Tank Description: SQ 41A44 611?/ //TN <br /> tet•sat•ssstrti•tttatratittawtttitstt••trues♦»ist»>tttsstittssstaa>rtstts♦•s•q>tairssttrss>satatsasx>r• <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. W KC &147' ENt/!2o rjMEA/ TAL SEAVd GCs EeU C. <br /> Address: I 61 1+r GL VtEtAJ WA} j City. TRACE/ Zip: 95376 <br /> Phone #: ( z 61 S 53" 07 Sg Date Tank Removed: <br /> uussua>rsuuutu utt•fiats ruu•Yuu>trtususat tttt stustsuu•iut••aut••t>auu>uuuttataaiss• <br /> SECIION 3 - To be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor: ✓U 2i 6714 7- <br /> Address:- <br /> t'� l 2 oNMEjU7At SE2VCGcS 1�1IC <br /> Address: l9(0( llLtU) [NA City. T,Pwy Zip: x/5376 <br /> Phone #: c Zoy , 933' C) 7St <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 /> '. tttttt>tiiYiiit!��it>tttttttrtttt>tttita>tt Ytttxtttiatttttittt>ttittttttYttt tt Ytttti tYtttiitt>titttiiittt>• <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: -riR F41U E L 1= 0 F SACK AMEPV70 CA <br /> Address: 3SZ S Z 1-C4 A Ur _City Zip: ryS8Z3 <br /> Phone #: ( C7 U ) 1 Z 1 — 15 C/ 0 <br /> Date Tank Received: <br /> Signature: Title: <br /> ssaisstx»••aaiisats»ssutsa rss u:rrsss>air utaisauaa aY Ys rats•iuxaiixsti iasx>a rsssaaaasa>asuraat rias <br /> EH 23 O49 (Revised 7-10-92) Page 10 <br />