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AL r 199
<br /> ENVIRONMENTAL HEALTH
<br /> PERMIT/SERVICES
<br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<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 /> recycling facility. The permit
<br /> holder is responsible
<br /> � for ensuring that this form is completed and returned
<br /> FACILITY NAME
<br /> FACILITY ADDRESS: Sl�� /C, ��T/�t S1�i T/��� g '3 7e5,
<br /> TANK ID #39 - sf0 —D/ Tank Description:
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<br /> SECTION 2 -To be filled by tank removal contractor. (�
<br /> Tank Removal Contracttor. ll.1,64-) rnm12irSUt�tnL `�RA(tLIF5
<br /> Address: �• �• t)c 21 City:y. �Qom Zip:. `!�
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<br /> Phone #: (1i 0 ) 034 ' 6�Cd Date Tank Removed: �Z3Lq+
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<br /> SECTION 3 -To be filled out by contractor'decontaminating tank”:
<br /> Tank Decontamination Contractor.
<br /> Address: City. Zip:
<br /> Phone #: U
<br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an
<br /> approved manner as required by Cal EPA.
<br /> Signature: Title:
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<br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility
<br /> accepting tank and/or pipin
<br /> Facility Name:
<br /> Address: ZSS V9 City. kLV1QUa"-30Zip: C14801
<br /> Phone #: ( Co ) 235 - i3q i
<br /> Date Tank Received. ("I L3 l q
<br /> Signature Title:
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<br /> ER 23 049 (Revised 7-10-92) Page 10
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