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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: v.) G l s I_ AN i7
<br />FACILITYADDRESS: Z\334 W. STATE Zav E 4 STaCKT IIID, CA gJZO(o
<br />TANK ID #39 - Tank Description: i S 1NG l E I,., Fat_i, 15 E-£ L
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<br />SECTION 2 - To be filled out by tank removal contractor. S I}TWGAfZ Ai bTg- _P A b r lO _
<br />Tank Removal Contractor. F- r,3 I,IM ENza L� Se e Q C 4 > rJC.
<br />Address: 4 ZZo Com m Etc \(a� �R . y S rt . S City \ 0.A” CA Zip:
<br />Phone #: z oq b -n O'1 S Date Tank Removed:
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<br />SECTION 3 - To be filled out by contractor 'decontaminating tank':
<br />Tank Decontamination Contractor. w �"i \GFcT f 4 TA t, S C it \j \C £ 5 t rN C -
<br />Address: KZ.ttz-, CQMM ct2 eluILl�R. t S-ri: , S City: 1\'oAeti c CA Zip: q5 3lfo
<br />Phone #: (Zed) 833 — y`1 SEs
<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: 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: 1Ci\ykt,)r E'- oc SACQtamel,TtJ
<br />Address:—'s25 SZlvo PAQEn),36(;Mj.%ox-al kCirr.SACRcu�ctitol�F1 Zip: RS623
<br />Phone #: () `-cZ\ —\g417
<br />Date Tank
<br />Signature: Title:
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<br />EH 23 049 (Revised 7-10-92) Page 10
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