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a, ly�i'4"�,r ROr,�y, • • <br /> � IfiM <br /> SPY <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ODr•Re•rre•e••sego k0 radar rrsre rtr••r•.Or•rr•br•ei Trie•rr•ss es eretlsSD ss•assaee58.4 ssbbr•r•rrsr♦stirrrbrirass ' <br /> SECTION I - Public Health Soul= Tracking Sheet will accompany each tank afHzed witil Its sits ldontiCacaticn uumbew. <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 persalt holder Is responsible <br /> for ensuring that this form is completed and returned <br /> FACILITY <br /> FACILITY ADDRESS/Cl <br /> TANK ID #39 - P�6-SL) –d Z—Tank Description: /a u 6 ° <br /> •H••rr••••r••r••r••t•Nr•••••••r•r••J•H•r•H•••NH•••s•ss•s•r••••••ss•s••s••sr 1•r r•r••rr N•N•�•rNr•••r <br /> SEC110N 2 - To ba filled out by t nk rem tvzl ntractor; <br /> Tank Removal Contractor: ce% yn jl 10 <br /> '' rI ! <br /> Address: gro-D NO. a.,ulz+j �Sl� City: C51",ToZ1p: l7 <br /> Phone #: (ZCq )1141 q—,?L3, , Date Tank Removed: <br /> � •.••.....r••.rrrr.rrr•rrrrrr•�•........�..•.r•r•r•••rrr•r•••••r•r•••••r•r••••......••...•.....•..••.......• <br /> SECTION 3 •To be filled out by contractor 'deoontaminating tank'. <br /> Tank Decontamination C/oouaetorlsTr)4 nJ r 'LRAVr cP_ �C)Aj S C <br /> � <br /> j Address• V ND, u,J(ay St7: Cltys��c.{C�tsU ZJp:�%�70�` <br /> Phone #: (?OQ ) <br /> Authorized reoteaentative o ,contractor cert"g through signature below that the tank has !M^n decontaminated is an <br /> approved er tqufr, by Cal,EPA. <br /> Signature: <br /> SECTION 4 -To be signed and dated by an authorized rspresentathe of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. / <br /> Name 1 <br /> Factiity NamE 7-K-- — / <br /> Address: �. 0 /pn1LJ0DrQ Clty` --te <br /> Phone #: ( 7-0? <br /> Date Tank ReceivFA: <br /> Signature: - \Z-: <br /> FN 23 049 (a.vls4d 7-10-92) P69e,10 <br /> i� <br />