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UNDERGROUND STORAGE TANK DISPOSITION TRACKING 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 Crr�j 19F Tk,4CLI
<br /> FACILITYADDRESS: /D wEsT 6kAA)r! £.UF 60 T/tAcy 69 9537!
<br /> TANK ID #39 - Tank Description:
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<br /> SECTION 2 - To be filled out by tank removal contractor:
<br /> Tank Removal Contractor. " 1_j tiVr�O.+Ji�1E.0 iL SE��1Gt-5t�✓�
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<br /> Address: l�61 A/ZLC VTAXI City AT Zip: 4s 3�6
<br /> Phone #: ( 7nY 1 i33- 6-7SY Date Tank Removed:
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<br /> SECTION 3 - To be filled out by contractor 'decontaminating tank':
<br /> Tank Decontamination Contractor. wRze.Nr :.,yu /LCA&M&,w74 SE.2r4I66 S I-JC
<br /> Address: lSG( l`LL( I)SEN) l AU Z City: rQ.FG� Zip: 9137,/,
<br /> Phone #:
<br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an
<br /> approved manner az req ed by Cal EPA. PQ-.Ca—t::-c7- MAY\)AC E2–
<br /> Signature: 7�y ean� o Title:
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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.G4rJ (r I- OF –SAUAM&VM
<br /> Address: 35 Z S SZ N A I)t City 4ACLft,MFAIW Zip: —95-
<br /> ZZ 3
<br /> Phone #: c 9LL `/Z/ - nlD
<br /> Date Tank Received:
<br /> Signature: Title:
<br /> EH 23 049 (Revised 7-10-92) Page 10
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