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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD � jL <br /> ' esrtsx###s#rfirs*ssss*stxtrtrttrtrrtr#rrrrsirr*rsissst+rrrt###ssrs*sertrt#t#srtstrs#ssrsx#srssesrrsttsessss <br /> SECTION 1 - 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 daXs of acceptance of the tank by the disposal or <br /> ' recycling facility. The permit holder its responsible for ensdring that this form is completed and returned. <br /> FACILITY NAME: �.J -J��� ` J ,JJt _ ? a? ( E <br /> FACILITY ADDRESS: ! <br /> � r <br /> TANK ID #39 - v1 1 �� Tank Description f.,r�'" /✓ LE (r�l�' . fir' / 'F'j. 1ta <br /> 1 #*rsr*rrxresests##sstsiissrsrs*RRsist+•r#s#s*rr##.rrrrsrsrs#r#rrr*tsr•rs#ss►***#srrsrssrsssisrssri**r*#sss# <br /> SECTION 2 - To be Tilled out b tank removal contractor: <br /> Tank Removal Contractor: � fr,4� � - <br /> 1 . r era ,�•• � 4 <br /> Address: cJ.. �- �! r�,�, City: f`3C� S JU Zip: <br /> 1 <br /> Phone #: ( Z&5) �'� 3 9f <br /> S% Date Tank Removed: <br /> ss###sts###rsttssss#*##sssssttstrtttsstestrrss#sss*trtssxtssss+•strrss�ttrtstssssirsssrts#st*t#ttsrrttrtrtr <br /> ' SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: . -,V5 0(- Co <br /> Address:� 7 Y"p °-�' �i , �.�F City: FR f.SA.)a Zip: r 0/ <br /> Phone <br /> ' Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required <br /> by Cal EPA. <br /> 01 <br /> 1 <br /> Signature: 'i `,' -Y '- 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: 117 <br /> Address: City: o G�c Zi ; r <br /> r t p: f <br /> Phone #: ria Y - <br /> Date Tank Received: <br /> ' Signature: Title: <br /> #tttt##t#r#txtrtrt##•rxsii###x#t#xtR rtsi#r###t#rs##st#r###fi#trs####rests#r####t#txR ri ti lx*#sRt Rstxttt#t <br /> ' EH 23 049 (Revised 7-10-92) Page 10 <br /> 1 <br />