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ENVIRONMENTAL DEPARTMENT <br /> A OVC-G OUN® STORAGE TANK DISPOSITION TRACKING RECORD <br /> acking Sheet shall accompany each tank affixed with its site <br /> SECTION i Environmental Health.Departments Tank Tr <br /> identification number. The Tank Tracking Sheet is to'be returned to the 1�_:nvironrherital Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holdea°is responsible for ensuring that this form is completed <br /> and returned. / <br /> FACILITY NAME: / � �/ ? �`< p Z <br /> FACILITY ADDRESS: d (G' �J�'i2�' ✓1� G�' e r 1� `= � u �` / ` <br /> TANK ID#_ 042TANK SIZE: �'�!��,� �✓ PREVIOUS 1ANK CONTENTS. X ds' <br /> Via.-aica�c,�a«kktexhitk *$r3rk�F�aYt�^/rir/e�tYefHeec##drdclrir�ir3nHei:�srk #inlrak`ki�Y7§nl•#� ir��i4.�#7r&dr3t'.r& <br /> SECTION 2-To be filled out-bey tank removal contractor. <br /> Tank Removal Contractor <br /> �5 / CRY: / fir' O —zip., 5 <br /> Address: p. — <br /> Phone#.�c? � Date Tank Removed:- <br /> SECTION <br /> emoved°SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination'Contractor <br /> Address: Tl CR'/ --Zip: <br /> Phone#:( ) 2_ 2 5'7gl <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA 's <br /> Name:de Title: SignatLre: <br /> IC1YitStN'��'�'�:'�9Y�$'ft{CA''.1�'�'ft'�*Il1ki�C]�$[.�CiC�ML'�'.�' i�1Y'C�'i't"�'1Y�' �f�'�'3"�'/l'+RL"�'71'A'SS9r'�C�C> � «•ff� <br /> SECTION 4-To be signed and dated by aq authorized representative of the x reaiment,storage,or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: J 4111 QIZ 11_b, _ <br /> ' S <br /> Address:- 62ep��, �i' ���� ��✓'r� ` ��Cit�a � Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name:r"f l �°t lr,� lt! ?rtie: A�� Signature:, i� �, ' i 1]ate <br />