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ENVMONMENTAL HEALTH DIEPARTMENT <br /> 1j0oV9GROUND STORAGE TANK DISPOSI-,11ONTRACKING ECO <br /> SECTION I Environmental Health.Department's "tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the En-ironmental Health Department w1thin 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder m; responsible for enswing that this form is completed <br /> and returned. <br /> FACILITY INANE: � IZ,51 7- Z-��,JZL 5 <br /> FACILITY ADDRESS: L5 r� <br /> TANK 1D =0` _ TAPl1{slzt=: ' � ®PREVIOUS TANK CONTENTS: <br /> SECTION Z-To be filled out by tanlk removal contractor <br /> Tank Removal Conor. *✓��d/�� rf� ,°r�t�°'� <br /> y r� <br /> AddressCity= .2ip: <br /> Phone* a ' � � Cad Tank Removed'- <br /> SECTION 3-To be filled out by contractor"d.econtaminating tank": <br /> Tank Decontamination`Contractar�- ) ' � e✓. {" // <br /> Address: �� City..- j 25p'--�--'` 1. <br /> --- �g <br /> Phone : <br /> Authorized representative of contractor certifying through signature below that the tank has beers decontaminated in an approved <br /> manner as required by Cal EPA ' <br /> Marna: e ✓'dfi� f01/ tle .s.�� �` Signature; Date <br /> SECTION 4-To be signed and dated by aq authorized representative of the tre Ament, � lie, r disposal facility <br /> accepting tank and/or piping. <br /> Facility Name. /� � dna ��� ��✓°� , . <br /> Address: — City: /��G�G�� gip: <br /> Phone#: <br /> Date Tank Received <br />