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j SM :AQUIN COUNTY PUBLIC HEALTH SE: �.I:ES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> a=»#####aa####rt*#*#rt##=z####kk#####a#k####*#rt#*ka#zz###*#=##»#z#z###ak#=##»#rtz#»kk####»»kk#####kkrt*#*#rt#kz# <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 disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and <br /> rereturned. <br /> FACILITY NAME : Lr , 1G /1cA <br /> FACILITY ADDRESS : -2G&-S, SaS T E�IR TMO MX- Si r e e + <br /> / c ) coo 9F11. A <br /> TANK ID #39 - TANK SIZE: /a a • rnrsAar% PREVIOUS TANK CONTENTS : U-1 he,91> o SC'vrIIAf <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank RemovalA -4A1 y Contractor: C Qr7 Ce a ` ny ;to n n ? 4-ki 7t1( <br /> Address : 9 Q D 5 Aj ,) A i N 11/ Jm(,1l/ A �f City: S70 C K in ✓n Zip :XXXXXXX <br /> Phone #: ( 2 04 ) 4 7 10 CA& Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : 1 <br /> Tank Decontamination nCo�ntractor: AaynNC ?o CtcEnvia /1rt1P ,* I Ar. , [[]] r[ <br /> Address: n5 5 Ala p -r I tilt %toyio ;' City: S Tc C K i o ll zip: '17 .7 5� XXX <br /> Phone #: ( 1� tl ) 47`X/ M6 <br /> Authorized representative of contractor certifying dtrough signature below that the tank has been decomaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <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 Name : WEST Cr A-S T c is % n tUl F 11/ 1 <br /> Address: � O . QO4 ,r(�� City: � C ' Zip: <br /> 963e/ <br /> Phone #: ( �O ) S� 93 7V <br /> Date Tank Received: <br /> Name: Tide: Signature: Date <br /> EH 23 046 (Revised 10/ 19/98) Page 10 <br />