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(� SAN h. UIN COUN'T'Y PUBLIC HE'ALTS SER y :S ENWRONMEMAL HEALTH DIVISION ' UNDERGROUND STORAGE TANK DISPOSITION TRACING RECORD ' SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affined with its site identification number The Tank Trackuig Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that ' this form is completed and returned. FACILITY NAME Cc)ll.N iY dr aKt,) ' FACILITY ADDRESS _1 .1(� 1P,A5Z NA.Z EL i onl bio G,&j n Q ax 2 d cs TANK ID#34 - TANK SIZE PREVIOUS TANK CONTENTS. ' �*�*#######�+***�*w+sw�*,«�****.*****.*#s*.*#.*��«:+�*�wr+r*+r..+.*#+*#**++*****�******s•,.#+#sss�r+mow#+*rss.#rr**+r SECTION Z - To be filled out by tank removal contractor- Tank Removal Contractor- SI&X- 1<-Tom . � aIN L ' Address 4 b1 Cry-S"CUC V,7 V N Zip- �5 2D 5 Phone#• } - Date Tank Removed: SECTION 3 - To be filled out by contractor"decontammating tank' Decontamination Contractor: ty^ S 1 N L. I& Address. %Q-k4City-$�o C-yk'W M Zip: 9 ra?_U S. -- ' Phone#• (?L() Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved ' manner as required by Cal EPA. Name Tide: Signature: Date ' #*+#•�F*i�ItiMpk+Mt*+f#�kiN�k*�M#+#+##MnF**#*�k�k*+MI+M*�M�F#�M�M#*M��F*+�F##*M**�F*I�M+MSM+MSM#t#*�F�Y�k�kiF#irk*�R+##*+#*#*y�+*y��tiF**M*�k*## SECTION 4- To be signed and dated by an authorized representative of the treatment, storage, or disposal facility ' accepting tank and/or piping FacilityName. l ' Address. —\ Ciry•iuRU)L 1L Zip: R) S �p Phone# (?[�4 ) 9'3-7 B ,.. Date Talc Received. ' Name Title: Signature: Date #s*#+#*,ere*w�*#*��►+�**#*###*##*###*#####+#r#.r##*#+#*#yrs.�++M.*�*�+�#*r�**s*****#*:*r*#+*#*ss*mss***#*�+r*** ' EH 23 046 (Revised 10/19/98) Page 10 1