Laserfiche WebLink
UNDERGROUND STORAGE TANS DISPOSITION TRACKING RECORD <br /> •...a as o,.u.•aa..,.a u.•w.......♦u.v•u.a.•u u.......•...♦u...u.u......w..u..,...•w..o.....a.. <br /> SECTION 1 - Public Health Services Tracidng 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 of <br /> recycling facility. The permit holder is responsible(for <br /> ,ensuring that this form is completed and returned. <br /> FACII= NAME <br /> FACII=ADDRESS: I J <br /> TANK ID +If39 - Tank Description.- <br /> 0......*..*............00**...... <br /> escription:.................................wu.,..e........o,aa.aa.a,,.• ........ <br /> SECTION_ - To be filled out by tank removal contractor <br /> R/ <br /> Tank Removal Contractor. (rte/ C`-� C I�'_7 �1��+ <br /> Address: C [ l 1 i ��, f l_ �� t , City: i F rN ;F zip: �r ) <br /> Phone #: Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank*: <br /> Tank Decontamination Contractor. <br /> J <br /> Address: ��?� l � Iqn, City-/2 !)ori/;i f-'' Zip: = �� <br /> Phone #: (_ <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal FPA. <br /> Signature: Title: <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: <br /> Address: <br /> City: Zip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title- <br /> •...u.,...,..,.w.,•q.v......o a,...a........a..ws.....v..a,..•aa.ou..»..w.w..,.a u,»v v,v.u• <br /> EH Z3 049 (Revised 7-10-92) Page 10 <br />