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UNDERGROUND STORAGE TANK DISPOSITION 'TRACKING RECORD <br /> SECTION I - 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:('- <br /> FACILITY ADDRESS: ";7'( <br /> AME:FACILITYADDRESS: "> 7,[ j /_Af'i.9 =�C _�l l \ (�c � l �/'T. <br /> I <br /> TANK ID #39 - Tank Description: <br /> SECTION 2 - To be filled out by tank remo al contractor: <br /> Tank Removal Contractor: ��- -f- } U` A <br /> Address: X2_.0 N, (j✓lic)vA . ^ <br /> City: j4o— Zip: <br /> Phone #: ( ZC)Cj ) �h�k _ 83 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank <br /> Tank Decontamination Contractors-i C•.0' Vir'e <br /> Address: 61C% OF.. (',l✓ z)Y ,O Cit `S�l'C-� � Zip: <br /> C� y- _"ic. l <br /> Phone # «' <br /> Authorized representativ of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved m e req ed by Cal EPA. <br /> Signature: fL� <br /> Title: =7 <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 Nam eE c_r /�, ,A 1��xy�tiFrf/cS n l <br /> Address:�7iL/O /Vs3 .rr 1 Ahyer CityLST-Oek roN ZiT): 3 <br /> Phone #: (2 �9y� —E-2 2 <br /> Date TaRk-iteceived:���Q)� <br /> Signature: L Title: <br /> xx#*r*****r#*#***rr#*xrr**xrr***rr*xrrrr**xxrrr*##r***r#r***#x#**xr#****r##***#****#****#*****##******** <br /> EH,23 049 (Revised 7-10-92) Page 10 <br /> '# <br /> u"W. <br /> k�� <br />