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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> aaaiaaaraaraiaa>s>arsara>aaaaasirai>r»aa>riatiaaaaaisa>riasa>sarai>isaaat>siararatas>a>taaraassaraaraaaaaa <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 within 30 days of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: xiV7Z7iQ57777- - 7i C/G.< 4ef:5r/y6 CO�plp <br /> FACILITY ADDRESSr(//3� .�'pCiT'f SUT TON yTrEET .S;rZ%-- W Ch' 95206 <br /> TANK ID 139 `� —/) Tank Description: 404:p 64e4nV lyew O/L <br /> ase xss arrss sarraatarrssariq>asarsirsartarsaaa>sirarsaassasasaaaraaaas>rssarssarraa>sssa ra>saaaa rsarsaurax <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: SE44/J�Cp <br /> Address: /i/.3/ Ves-r City /�DDESTO Zip: 9S3S/ <br /> Phone #: c 2D9 S2 5/ 9FS3 Date Tank Removed: <br /> srssaaaraa>a sassasaassaa.aarass>raaassaraaarsatrsttrassass>trsa>araa>as>rrasrrsar sa>assrass>asarrs saarraxxr <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination ContractorS: �IW40 <br /> Address:_ /i/3/ "57-AZ9T AV City /� Ma5r,, Zip: <br /> Phone #: Z( 09 ) 525 9653 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as quired by Cal EPA- <br /> Signature: <br /> PA.Si;nature title: pQp - <br /> sassaaaaarss>aaaarssrs>rrasaasssaarsaas>ti>trsiroi>arsaaarssttas>aaastraa>rsatsaa>aia>as>arasarraaasrarxx <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: Z-/j1G p <br /> Address: 01.20 '9 fo X-p�Rcr City:_ �/Giy/hDw gip; 9//30/ <br /> Phone #: ( S/D 1 23(, 0606 <br /> Date Tank Received: <br /> Signature: Title: <br /> •saga assairsaa>r♦ iaaass-a>tsaa>s>riraaaa>tiasaa>firstsi>aua»auraata>ttaattasaira>»attas>tra»sa>rs <br /> EH 23 049 (Revis 7-10-92) Page 10 <br />