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F. 91 <br /> UNDERGROUND STORAGE TE M DISPOSIT ON TRACKING RECORD <br /> !##til YRM#R#Rtkftl;RlR#♦rtwritiR!#!ltfiYRR!/fYRw;#ik#t#tf!#!#rt RRR>♦f#f;###R:RR■XiR•;tf#t;#*#!l RrRMflXt Xl;i <br /> SECTION I - Pub& Health Services T:ad:ing Sheet will accompany each tank affixed m iih Its site ldentificition number. <br /> The Tracking Sheet is to be returned to Public Health Services within 30 dans of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensuring that t1tLs farm is completed and returned. <br /> FACILITY NAME:_S1 '� (, -, <br /> FACILrl'Y ADDRESS �� ��`;`�_.��� Lt'%�3 L4n C)y f� <br /> �r <br /> a <br /> tlYt#RRRlR•!R#!R�!*«#i#iRM!!RM#r!#itxti;wftfyyy#!#fkaif.k###fyas#;!###iiy*#ttf###f!!M#ilMt Xiki#i;fi;R;;;;#f;;R;; <br /> SECTION t - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ U.:pTi,r"t7or.� r-r_�CN k l i �(. i L <br /> Address: P.(D. o�C LCYcf�� Cityr c ' �kdf�yY� -zip: <br /> Phone ..� t � Date Fink-Removed,— LT <br /> �-'� •D.. -: � Nil <br /> #fR!!#R!#!\#Ir!##YR##i!R#tt##f RrYrR#fR##i###!i#f#i##►##airy####\####iffy#;RRy;;♦##f#tRktR it iYafi R+�Y ; R <br /> SECTION 3- To be filled Out by contractor'decoutantinating flair <br /> Tank Decontamination Contractor. UJ P++�`> 1 � 'G <br /> Address: � <br /> r City:X14 ,zip= <br /> phone #: <br /> Authorized representative of contractor certifying through signature belrm' that the tank has been decontaminated in an <br /> approved manner as required 13y Cal EPA_ <br /> Sigrlatntt���' St�� � <br /> Title: <br /> RtR;tit!*f♦tRltlMlN#=!#y!#i;lirli!#♦;#1 RRf Ra Rt####;#iti#tl Fif'Rtlk Mf#f t#; #;R#;r;w! #f tXt;fi►.Xt;lt#!#R##Yl Y; <br /> SECMON 4 - To be signed and dated by an &Hthorized representat m of the t t9aent, storage, or disposal •cili <br /> accepting tank and/or piping. �`to> cornf'c- r+ c w <br /> Facility Name: 0�S�� ( {� (•U ��t-a <br /> Address; l -'2_;� J <br /> Gty: t �i� z;p:��2� <br /> Phone #: <br /> Date Tank Received: <br /> Signature: <br /> Title- <br /> ##iy Rtiwi RMRritRri#i#iii;##Rif;Itl;;rt####;##iRf XrXlY#*a!►::!}!#t1;Xlr k;af#!i#R;###fir;##ik#!!#!t###i##Y <br /> FH 23 049 (Revised 7-7Q-921 tape ttJ Post-It"brand fax transmittal rnerno'87i #Q <br /> T Z ` <br /> CO. <br /> Dept IN <br /> Fax Fax 4 1 <br /> h Lt <br />