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ENVIRONMENTAL HEALTH DEPARTMENT <br /> , j3oV9GROUND STORAGE TANK DISPOSITION TFtACKING RECORD <br /> SECTION 1 Environmental Health-Department's Tank Tracking She.;t shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to'be returned to the EFivironmential Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder s responsible for ensuring that this form is completed <br /> and returned. r } <br /> FACILITY NAME: <br /> FACILITY ADDRESS: sc I Og <br /> TANK ID# � TANK SIZE: PREVIOUS Tt.NK CONTENTS:___L) <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor tom., /?� ��' �� � < <br /> Address: (� 3 city_ /_) l _Zip: <br /> Phone#:Y Date Tank Removed- 1 <br /> SECTION 3-To be filled out by contractor"decontaminating tanW'-. <br /> Tank Decontamination Contractor. <br /> Address: 1. ._15 2 _ City r Zip: l <br /> Phone#k <br /> Authorized representative of contractor certifying through signature below that th tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> ®®� �� ilei -c _e' Si natur:: �- :!% ./..-Date "® -✓"� <br /> Name: -T t s1� g <br /> * * �r �rx � Rratcr ;t: drstr * arra <br /> SECTION is-To be signed and dated by ap authorized representative of the treatment,st+ ge, r disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: 5' G <br /> Address. -t S( � � < -city:, ZIP: J <br /> Phone#: <br /> Date Tank Received; 1- ` f V <br /> Name: C��Gfr°� /(S f T 6tte: � ( Signature: - F�., Dat@ _ <br />