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' UNDERGROUND STORAGE;TANK DISPOSITION TRACYJNO RECORD <br /> tfM�YI#MMVM•IMfNr4#FY##1lkRtti#4Fi4444i#t#4#M44t!•t*R*44*4*Ri4#*14FiRF*64000#FM#tot YMMi#6t I$$*to MiYittt <br /> ' SECTION i - Public Health S'crvices Tracking Shed w4I1 accompany each tank ai xed with its site Identification number, <br /> no Tkackto Shoat Is to be returnM to Public Health Sefvlecs t d s of acceptance of the tank by the dfspoSal or <br /> re ytling fadlity. The permit holder is responslblc for ensdring that thk t'oM is Completed and rettttnM. <br /> FACILI'i' NAME:� .JS oA rJ i* I t !t * t MA <br /> FACILITY ADDS: li <br /> ' TANK ID x#39 - Tank Description: <br /> !##M#l#YFf*#0ii#i#i�ltR4#•7r4t4tR4rFR##F r4t4444+*IT Its 4*F*R4d#*4i9F*#**#4$It*iii#'4#k#*444#444#40t4FM-R##4i*ti <br /> SEMON 2 To be tilled out b tank ramoval o(�ntroc(or, <br /> Tank RemovaI Coatractor: eo <br /> city:. �i <br /> Phone #: ( � ' _J bate Tank RemoyM.- <br /> M4000**4k0MrtRosstit'0*4444#tto44R4##if***00*to44t44##t Farr##4044*tr0a 4t4#R44♦F 1.M0*to 04MMi4ti#4444►#*ar.##:444 <br /> SEC170N 3 - To be filled out by contractor "decontaminating tank"; <br /> Tank D=n(atninadoa Contractor: i )/1 (10 <br /> Address: ` ' J Uy:� i�:�, c� Zip; • n _v. <br /> ' AULb0iiz.r,dreFrtsvrits+lve of^ontractor Certi-q thro ugh aig;t;��ure b:;�w tftat fife tonic has been dccvntaminated to aQ <br /> approved zi>atute required by Cal EpA <br /> Slguatara; �'lyllc: , P. ---.,_ ------ - <br /> ' K4##4.*iRR**lRROR##F4:iR+Ftit#t###R4##i#tfi#,4M}#4Ft41fFR4fFM06MM1MRFFMMM*tFFkMMM##i#4FM0i##ORRM#4.4#4t4R#004400• <br /> 99CITON 4 - 'Tet be slgnod and dated by an authorized representativ€ of the treatment, storage, or disposal facility <br /> a ceptltg 186 and/or piping. <br /> facility Name: <br /> City:n?#?C� .- zip., _ _ .y <br /> Phone #: <br /> Date lank Roceived: <br /> ' Title; _ ' r�� z <br /> 1 <br /> 1 <br />