Laserfiche WebLink
UNDERGROUND STORAGE TANX DISPOSTITON TRACKIIN RECORD <br /> isa..i..i..aa..aa..f>faalaf>afaiati>aaaf>as...saafaafafifii.faaiafifalsfilfafiiialiialfllftilaa.aaaa. <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 /> reeycdag facility. The permit holder is responsible for ensuring that this form is completed and returned- <br /> FACILITY NANE: bPw)5 VT-1rL Ch�L,�.✓tcAbA <br /> FACILITY ADDRESS: b -I�M (I`,igkki/��- -/ <br /> TANK ID #39 - cZZ i LSS Tank Description: <br /> ........................................................................................................... <br /> SECTION Z - To be filled out by�a� owncraror. <br /> Tangy Removal Contractor. `` �� <br /> Address: 17/17S / O� City. Zip: <br /> Phonem: L� <br /> �7 <br /> Date Tank Removed: <br /> ........................................................................................................... <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor: <br /> .1 Ci �rYC,� Zip: 7 S I <br /> Address: 7,1 r 5 ff �� <br /> Phone �: ( `�I <br /> AuLlIOrzed representative of con=dor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Signature: <br /> Title: <br /> ........................................................................................................... <br /> SECTION 4 - To be signed and dated by an authorized representative Of the treatment, storage, or disposal faciliry <br /> accepting tank and/or piping. <br /> Facility Name:: /VI�oe-,SLI o �u{�(L Co �t <br /> Address: I '1 y 7, ",.I^I f� J� City �r �r Zip: <br /> ] ` 7 S <br /> Date Tank Received: <br /> signature: <br /> Title: <br /> ...........................i.a.i...i....>....ii...........i>..........>..>.............................. <br /> E4 23 0:9 (Revised 7-10-92) Page 10 <br />