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1C - <br /> UNDERGROUND STORAGE TANK DFSF'OSITFON TRACKING RECORD <br /> Yst*if#4t#tf*ifi###f4##if#t#R##ttt#4fffittf#fYfttfttlftff iitif Citi#tit#i!##tlf ftffffltt#f R4#*t!*#44ii♦#♦##f <br /> SECTION I - PubIic 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 easriring that this form is completed and returned. <br /> FACILITY NAME: F><rJ JOA 0,-) 1 L 7 jGLf _ -�i/ ►ter.r t. "J, C... <br /> ' FACILITY ADDRESS: F�j �"' t;4 J ' '�C,t!eC:.� ► S� J� <br /> TANK ID #39 - Tank Description: JU <br /> #*4«#ii4t Rtt t##flfiR46t#R###f tt ttttlt«it«ttt«tt«ittt««tftiitltttfffttttt#*lf4fi#tf tfif#Rt4t#«««44i#*Rt#tt#f <br /> SECTION 2 - To be filed out by tank removal contractor: <br /> Tank Removal Contractor: �k'S -• C'0 <br /> Address: .=`�y 'f r ,,a;,.s /lop. Gty: rz: 5.)'On Zip: 3 20J <br /> ' Phone #: , ' - Er`le Date Tank Removed: <br /> *#f#tt4t4#•#44#iff#f###########iftt!!lftetft«ttlfiltftitif4titftf4##t!!!#!4!#ff4##t#!#*t4lf 44l i#Rtflf#####i <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor:_ <<JX :v-. req <br /> Address: d{f0City: Zip:_ ' - coj <br /> Phone #: 2— 4) <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: <br /> sif#!*t#s###t Rt4#4s4sfst#ssf###sRit#*ti#!tf««iYtss#tRsstit#istfff4littsftss#t#*t4iiittttfffft##itlt#f4si#if <br /> ' SUCTION 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: ", 1 s7" <br /> ' Address: r it, 1 rl." t it .. g 6 4 <br /> /l..a� •,;, Qty: ,��/r��ri?G�. Zip: <br /> G� A <br /> Phone #: ( ) 4 6'- V ' <br /> ' Date Tank Received: <br /> Signature: Title: <br /> #*•l4it•lRff#Rift###4iif4f#4iif4f Rifft#iftftfftiYii Rt!#ffi Rf RfftRiifti#tttt#*#4Y4 iii#*ltft#t#!###t!l Rtff <br /> ' EH 23 049 (Revised 7-50-92) Page 10 <br />