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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ..,......t.................................................................1.1............................ <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking <br /> Sheet is to be returned to Public Health Services"'(W 3l1 devs of acceptance of the tank by the disposal o <br /> recycling facility. The permit holder is responsible for ensuring that this form is completed and return <br /> eCL <br /> FACILITY NAME: <br /> FACILITY ADDRESS: /D W657 bkAoUr 12,4cy 9 37! <br /> TANK ID #39 - /�cl Tank Description: <br /> ......................................................................................................... <br /> SECTION 2 - To be filled out by tank removal contractor:tractor i2�I Ct S Ss1/C <br /> Tank Removal Contractor. <br /> Ci AG Zip: FS-3 7Z <br /> Address: l q 4l City: <br /> Phone #: ( Date Tank Removed: <br /> 7�5 ) �33" D> S Ff <br /> SECTION 3 - To be filled out by contractor'deoontaminating tank': T�ir <br /> Tank Decontamination Contractor. wRLGNT riyitL/leiyPtltN�TAI SE2u�G� <br /> Address: lSG/ IJLG/, IIZEN `� <br /> Phone #: LZD�-2 <br /> an <br /> Authorized representative of contractor certifying through Signature below that the tank has pS�T��EC <br /> approved manner as req <br /> by Cal EPA <br /> Title:u <br /> sigllatnre: ........................................................... s,....•,�... <br /> ................ <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 /> 1 <br /> Faciliry Name: 7-/ .LAA) C l� F S/9(.fAM <br /> iZip: 9 rR7 3 <br /> Address: <br /> 35ZS S2 A1fF City. SAckaahcA?LQ <br /> Phone #: <br /> F <br /> Date Tank Received: <br /> Title: <br /> Signature: <br /> l au..axssxsxxa..xssus <br /> xs........saxss.s......sss......................... ................a.++...+.• <br /> 1Page 10 <br /> EH 23 049 (Revised 7-10-92) <br />