Laserfiche WebLink
UNDERGROUND STORAGE TANX DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Service Tracking Sheet w11I accompany each tank affixed with its site ideatifacation 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 ensuring that this form is completed and returned. <br /> FACII.= NAME: W,,*m to r <br /> FACILITY ADDRESS: CIS�B �. 4UM'Iuvt f&M , fveoe-h &w p , eA <br /> TA:`+xID #39 - Tank Description: (D0c70 (Do bvtes-et + (jsStclkle {�t%jiurr <br /> ........................................................................................................... <br /> SECTION 2 - To 6e filled out by tank removal contracor: <br /> Tan: Removal Contractor ��wfCb <br /> Address: iZ i l l c� Cin: Zip: t <br /> Phone T' ( Zt7r1 )�`�6�'✓ Date Tank Removed: <br /> .......................................................................................................... <br /> SECTION 3 - To be Oiled out by contractor "decontaminating tank": <br /> Tan:: Deco ntammaricn Contraaor. 4EA,(Lo <br /> Add:ss: (2 t t J{ , Cir. / AOCIPS(40 Zio: <br /> Au or zed rept s na ive of on raeor c rt tying through signature below that the tank has been de anmm sated n as <br /> approved manse: r uired by Cal FPA- <br /> 5 <br /> PA. <br /> Signature: <br /> I — Title: <br /> ........... ............................................................................................ <br /> SECTION 4 •To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> a=ptiag tank and/or piping- �,( ,'n C <br /> ku <br /> Faclity Name- ""'u <br /> Address: Z "t� ` % City Zip: <br /> Phone m: <br /> Dace Tank ^i <br /> ;ianatur- i Title: <br /> ....................................................................... ...........................,.... <br /> E4 23 049 (Revised 7-10-92) Page 10 <br />