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N _ <br /> I <br /> SAN dOAQt.: iN COUNTY PUBLIC HEALTH SERVICES <br /> ENV MONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking. Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the ,iisposai or recycling facility . The permit holder is responsible for ensuring that <br /> his form is completed and returned . 1 <br /> FACILITY NAME: <br /> FACILITY ADDRESS : tQO <br /> TANK ID #39 - TANK SIZE- : _ ODD PREVIOUS TANK CONTENTS : <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> rank Removal Contractor 5j;n ,t_ AZO vIZ e� ��] � t <br /> - � ,4d <br /> kddress : Rog L62 ! r� 3y� < l� City :, Ce4uZ �( k Zip : 9$ZCTS <br /> 'hone #: ( }i L/ C ) �� 3j Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor " d _contaminating tank" : <br /> Tank Decontamination Co//ntractor: ./�n�l< iZbtl ����e/[Cf- v� } JCt ( Tcu C. , <br /> kddress: [� N � - ( # �/ [ O � j Ci r r <br /> ry:� YDr.� Zip: <br /> ?hone #: ( 261e <br /> kuthorized representative of contractor certityi: , through signature below that the tank has been decontaminated in an approved <br /> nanner as required by Cal EPA . <br /> Vame : Title :_ Signature : Date <br /> SECTION 4 - To be signed and dated by an auc4orized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping . <br /> i <br /> Facility Name : // <br /> address : r/� cl �6u L( )YtC AELi T City : �[[��GL Zip: ez <br /> Phone #: _- <br /> Date Tank Received: <br /> Name : Title:__ _ Signature: Date <br /> i EH 23 046 (Revised 10/ 19/98) Page 10 <br /> i <br /> i <br />