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1UNDEP.&I Nra STURAGE TANK DISPOSMON 7-*K2NG RECOf'C1.1 K . <br /> ' R1�#4RiMi*RlRM�!tlkliMMrtlrtriMtiRli#R:*lr►►riR.#!r . <br /> iRR#r**i*Rel►iiF#IIRRRR*#rtlRR#*1�'RfMRiRiMMki*RI'I+MlMRiM#RtRiR+, <br /> S!-r{rT'IbN 1 - Public Health Semi= Trackfng Shat will 9=11pany each tank ainxcd with its site Identification nvmkr. <br /> ' 'rne Tracking Sheet IS to be returned10 Public Health SODA= w1thiq 34 d yj of am ptanc0 of the tank by the disposal or <br /> recycUng NCMty. Tte permit hatdtr is resgonstblo for ensdring that this toad is completed and returned <br /> FACtLrN NAME, 4 .11 <br /> PACIL17Y ADDRESS; #`�7t i �. �,�•,j, i S v7 <br /> TAIL TIS #39 - �6 � Tank Description: .1000 , .J 6LC Nj tLr&.o 577 Ej W -ir— <br /> RRriRMitti«#iy�4kRfiRfWRiR1RRRi1ii�4iArIM!#R►ii#M►t##rRR#ii#RtkRR*�R�#►►#Rk►!!R*MlRkiiR'iy�rllR:i4kliiiiwltlt► . <br /> SHMON 3 - To be filled Ottt b tank removal CQ111rSCtor: <br /> i 'link Removal Contractor, „%,161 f'0 <br /> ' Address: (D3 f► '' - City:_ ��� Sa�*�..t ... �ip,Y, .374J - <br /> Phone �: ��„� � * Date Tank Removed: _ <br /> '#rt.R#"iMMir' {�t1ifRMI1RrtkMiRMfAitirt/�Eirrl�4i#iter**y*4*44�!i►*tie►karri#rt4*rile##►►.iilksr4RRR4* rili�.A#irMfrt► <br /> S8C ON 3 - To ha i'iltcd ottt by contract r edccantaminating tante"; <br /> Tank D6contamiAatlon Contractor: ,: is 40o <br /> Address: <br /> t ''� ' City: �' •J Zip;—��?/T��, <br /> Phono 7=; <br /> Autllorizcd rePrCSChtatfve of contractor ecrlifylttg through signature below that the tank has boett d�rttarainated in an <br /> approved trimer as r ' aired by Cal EPA <br /> ' //�• ti"CrF- �--4r...�--w -- _....� Title.: <br /> #R«RI*!wR•Irit#�iili'*•k�irtrti#i#rlfRR#trtFw#rri��lttt�k#li*i#file�ti*lRr/1!1##lIR1*rliRtitirr�y,�,ii1k11i/Yklr* <br /> s <br /> SECTION 4 - To be Signed and dated'by an Rulhertzcd representative of the treatment, storage, or dlspostai facility <br /> a=PSB UO andlar piping. <br /> F$etlity a� A <br /> az- <br /> Address: ? , <br /> Zip: <br /> Phone #: ( w 7 <br /> ' Date Tank Rawivad:, —'L <br /> �,��j <br /> signatur <br /> --- T1Q7c, :3 7 <br /> R'►Rrr#MSR�R##llres*R*r31#rtfl#F#RI.Rrr+#srr�wi►RRlRrsr{Ilrrwt##�rsfretr►► � <br /> R*#►R*r*k►l*#Rr�4ll#"riRRrtr4rtRi <br /> tEH U 049 (Revts&d 7-10-9Z) page 10 <br /> 1 <br />