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UNDERGROUND STORAGE TANK DISPOSITION TRACHING RECORD <br /> ....wwww>wwwwwu.•wwwwwa wywwwywwr w.awuw.w,wwww.ww•ax.....asuwww,.wuawww♦.w..uww..aw waw.w.wrwww.wwwwww• <br /> SECTION 1 - Public Health Services T racldng Sheet will accompany each tank affixed with its site Identification number. <br /> in 30 days <br /> tance of <br /> recycling f�acility.�The to be returned to Public Health Services <br /> holder is responsible for ensuring thatlthis form is completed andt ee tank by the disposal or <br /> returned. <br /> FACILITY NAME: NE 6!C7-q L4CL <br /> FACILITY ADDRESS: /D W657- 6R�ONf I z tic e O T12,4C y ��G��9 9s; 7� <br /> OSSrLiaLW <br /> TANK ID #39 - l D Z Tank Description: L J <br /> ..................www.ww....w...............w.,.....>rw....•r..............•..................w.rw.ww,ww.r♦ <br /> SECTION 2 - To be filled out by tank removal contractor E�(l <br /> Tank Removal Contractor. � �� <br /> Ci (wg6 Zip: X1537,6 <br /> Address: I96/ 1-�LLC F-A) lt/i4 / City: <br /> Phone #: ( 710 ) '933- 011 S y Date Tank Removed: <br /> wa w,ww.wuws♦www..•ww•wwww.w♦•.wu.u.wu.uuwww•u,..•♦wa.u..w.w••wu•♦wu,•,ww u>.u...w....www.wra..w• <br /> SECTION 3 -To be filled out by contractor 'decontaminating tank': rsJ� <br /> Tank Decontamination Contractor: t UkZG NT rn[ /la.y[�1 C/UT'9 L Sf EL1�GG <br /> Address: /SG/ ItLLI, 111�r� 1N City: j,L± Zip: 9S37L <br /> Phone #: , <br /> Authorised representative of contractor certifying through signature below that the tank has been Ttamin ted inan <br /> L E� <br /> approved manner as regt iced by Cal FPA. <br /> �� � w TiIOII9� <br /> Signature: Title: <br /> ww ,wwawww..aw•wwww.w••wwwwww.u• •wuuwwu s.w.,••.ww.•.u...ww.www.aw.w..u.uww.www ww,uw..w.f•u>u• <br /> SECITONu4 -To be signed and dated by an authorized representative of the trc3tment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: F9LAtJ Le OF -S�14PA f <br /> Address: 35ZS SZ /q l)f' <br /> City: Zip: <br /> Phone #: ( v4 6 ) `l Z/ — 310 p <br /> Date Tank R : <br /> Title: <br /> Signat . <br /> �,. .>.w..w.w>a,.>.>♦,.• ......w,u„..uua,.....•.u.,..,.w•s.•a......a................................... <br /> EH 23 049 (Revised 7-10-92) <br /> Page 10 <br />