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<br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIONG 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: THE Csr6 /)F TQAa/ -
<br /> FACILITY ADDRESS: JD w b 5 r 6RAn1 f L ZAJC jep Tdoc v C.9 9s3 7l
<br /> TANK ID #39 - ��— d Tank Description:----1 c.� U 67,
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<br /> SECTION 2 - To be filled out by tank removal contractor: ���
<br /> Tank Removal Contractor-10916442- �-61VJllO�MFiU7AL SE�rLICES —
<br /> Address: 1961 ,/ZL c vz cr/ 14JAL/ city: ?XA!2X
<br /> _Zip: �is3 76
<br /> Phone #: ( 7n5 ) '933- 6-2 S Fr Date Tank Removed:
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<br /> SECTION 3 - To be filled out by contractor 'decontaminating tank':
<br /> Tank Decontamination Contractor: wk.G(.NT riy(t�/laitJ6'i1cM/TAL SE.211IC6 S la/�
<br /> Address: 196/ I t9 ) rIAZA`/ City: re �G Zip: J5-37.6
<br /> Phone #: (2[A 0 7!7s
<br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an
<br /> approved manner assrreq
<br /> by Cal EPA
<br /> Signature: yG1 Title: �eI2J�y
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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: 12.c AN (rLb� Or SAUAMfiUTrh
<br /> Address: 35 Z S S Z �� /a up, City. ge*-4P lF&W Zip: 9 SX Z 3
<br /> Phone #: ( e l4 ) I-/Z I- �90
<br /> Date Tank Received:
<br /> Signature: Title:
<br /> EH 23 049 (Revised 7-10-92) Page 10
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