Laserfiche WebLink
UNIT UND STORAGE TANK DISPOSITION TRACKING RECORD <br />strutlsxss»tarturttsr •»»♦r•ssrxs+f+lrf stafftstrsf tlrsrrrrlfssr•frt•srf uttssts•xrlrt•f ratrtttssi• <br />SECTION 1 - Public Health __,vices 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`` <br />ensuring that this form is completed and returned. <br />L� <br />FACILITY NAME: X&/NZ <br />FACILITY ADDRESS: r%S7—'3:46 <br />TANK ID #39 - /3!!2Q — 04 Tank <br />}a�itlHHHtttifltlr+ilff ttitiixtrxrll rtf tttttiiri Hirtss rttsf lRitf ittittrtlirlltttii+t•ftixs+itl H•gtN• <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Phone #: <br />Date Tank <br />City: Zip: <br />ssf irif•••tttu•rttftf••lssrff rssssrr+sssssrfufssssssr rs srrri•rsrrsisssr♦rf srritt«♦sstrs+rssrsslistiisr+s• <br />SECTION 3 - To be filled out by contractor 'decontaminating tank': <br />Tank Decontamination Contractor: <br />Address: City: Zip: <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; <br />iitNtNlttti tttfYf tat ttttti ttf ititt Htl•btlrf tf trHlrMttx tl+itrti Mtttttt tttl Htiittiitttttttrltat}tttlt <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. i <br />Facility Name: <br />Address: City: Zip: <br />Phone #: <br />Date Tank Received: <br />Signature: Title: <br />attlitiisffrststaststrrlutstttsl•ffar»rslufsslfsrstsrtt•sufrlst ti•:rat •}sirs+rtfsslxsstsxtr»ittstlt <br />EH 23 049 (Revised 7-10-92) Pelle 10 <br />