Laserfiche WebLink
UNDERGROUND STORAGE TANK DISPOSITION TRA=G RECORD <br /> SECTION 1 - Public Health Setvic s Tracking Sheet wn11 acampany each tank affixed with its site ideatffcttion 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 /> rec/ding facility. The permit holder is responsible foris- ensuring that this form completed su <br /> and remed. <br /> FACII.ITYNAma Wamt6r ] O; /ll k(� <br /> F,,CM=ADDRE//SS: �iSDB l7. �ltwltwt fZdac� I v2HeG! &wap , ('A 1" <br /> 71*r< M #39 - /�7' �TankDescription: 10000 (od t leS2..t + (asgoclaTea Pplurr <br /> .......................................................... <br /> ........................... <br /> ........... <br /> .......... <br /> . <br /> SECTION 2 - To 6e filled out b,yJ� tank removal coatracor. <br /> Tank Removal Contractor. 4 C7 f <br /> Address: (2.L-7 � • - +41 City- <br /> ?to ad <br /> ircPhone m: ( ?01 ) �6�'J Date Tank Removed: <br /> .......................................................................................................... <br /> SECTION 3 - To be filled out by contractor 'decoataminaring tank": <br /> Tank Decontaminacion Coarrarar: 54EAC0 <br /> Addrl fj <br /> city: /t/6o1. esrlD Zia: <br /> Aur-hprzed representative of contractor certifying through signature below that the tank has been decontaminated is as <br /> approved manner as required by Cal EPA. <br /> Signature: Title: <br /> ........................................................................................................... <br /> SECTION 3 - To be signed and dated by an authorized representative of the treatmeat,storage, or disposal faclicy <br /> accepting rank and/or piping_ <br /> FacdliutyName: Lgety er 2 <br /> Address: 2?l( &16 /y 7,)Y, Clty: zip: gSl,�3 <br /> Phoae : <br /> Date Tank Received: <br /> iignacure: Title: <br /> ................................,........,...........,.................................................. <br /> E4 23 a=9 (Revised 7-10-92) Page 10 <br />