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1 <br /> 1 <br /> 1 <br /> UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD <br /> ' ***sssrtrtrtrtrtisrs*ssr*r****stttss!**r***s*R#****tsst**•*rrsss**stt***t#s****st*r********trt*rr***t#*t*r**ssst <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 wlthln 3(➢ days of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder iss responsible for ensuring that this ford is completed and returned. <br /> FACILI'T'Y NAME: ��,� 1 � 06D..)�.,j L"4 ? 14 rote ,���ni ��r?� �ie,J'...`, � <br /> FACILITY ADDRESS: V J CA J• .4 0 <br /> TANK ID #39 - Tank Description: /000 , a 6� .Jr _�,, r•, <br /> rt##RkrtRtt*t#*tttltlr4*tRet*t*etRR*t#rtt*tRs#ttt#ttrkt4#t#st*##t4kk*4tsiRR#trk#k##4###itksotsR.tt4ek**##***rt* <br /> SECTION Z - To be .filled out by tank removal contractor: <br /> Tank Removal Contractor: r �J•K' w ['c7 <br /> Address: $ r ( d'i3 J � t-� =-- City: Zip: <br /> ' Phone #: w Gt '�% ��� Date Tank Removed: <br /> *•r►*r**s*�**rrtstrtrt#rrtrtrtrssrtssssrs*•rt*tsss#ss*t#4r#rrsst•rrtt*trrtrtrstsrtsrt*******tr**r***sserts*r*s*rtss►rrtts <br /> ' SECTION 3 - To be filled out by contractor "decontaminating tank': <br /> Tank Decontamination Contractor: <br /> Address: ' ` P 7�f a v City: Zip: 'f <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 EPA. <br /> Signature: Lel-'I`` ') �'. `�"� + �^_ Title: IJ . <br /> #tk***it#*tt##*#r**#t*#!##iRk**trttt#*tt*iRs*s#RRR•4tr##**!*tits***#tt#tfRtk*!!!*f*##ttttRt*#rs#ttltstf♦*ttr <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: r',r;_�cry '"? +'.'+ {, ^" (qty: 1 � <:r(_� �e Zip: <br /> Phone #: ��� �� t")^" ` =} •� �- <br /> Date Tank Received: <br /> Signature: Title: <br /> #*#fft#t#tt#tt*tt#t#*tilttks#tst*tttirtt#iti**#!#sttf##*lttirt4ttttt*t#4t#RRtR##•t*Rrt4rtrttRFt4RR*s**tf h it* <br /> rEH 23 049 (Revised 7-10-92) Page 10 <br />