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i <br /> i <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ifiifif ilial iiffiitafiii►fra►i ai to to►iatiaa iiittiii►iii►►►iiiiiti►iiiii►it tairra►a►r ata►ii►i►iiia♦it►tai tia <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br /> J recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />' FACILITY NAME: <br /> FACILITY ADDRESS: / Z C S 6 <br /> Q ; I <br /> TANK ID #39 - 6�- 1 —O Tank Description: '2 d - �(AQ ��C- i <br /> ifif iiiiii►ifi►tii►i itiiti t►i►i til aiiiiiii ii ti4ii it alit►ii;itaiiaaii iiriitiiiiiiraiiii►♦i♦i itiriiiiaaia rata i • <br /> SECTION 3 - To be filled out by tank removal contractor: ` II <br /> Tank Removal Contractor:-STCnAg:Xh::) SF-ry/cam <br /> �1 <br /> Address: g�0 /�o �Nlow City:�T Zip:��1,�2d� <br /> r: <br /> Phone #: (ZO=�! ) '�S_{��� 3 Date Tank Removed: - / (J t-bp <br /> ii#if ifafii i�ia�aii♦itif•iiaititiaitritifii tiiitiiiiiatitii tiiiiii iaititii iiiittait♦iaifaiaifatai♦ii►til►ii <br /> SECTION 3 - To be filled out by contractor 'decont inating tank': <br /> Tank Decontamination Contractor:�fC' j <br /> Address&l e) aA�kc1A- ) - <br /> City:57 b4 Zip: <br /> Phone #: CZAID 49y'83 <br /> Authorized reP r entativ f contractor certifying through signature below that the tank has been decontaminated in an <br /> approved annersas req ired by Cal EPA <br /> Signature: <br /> iif atilt ai;i;iiiatia iii tiiiiii aiiiai►tiitiaiiti iii tCiti►ilial;aiaittiii►i alit#ii♦ii it•iiaataiatti►i•►til►ti <br /> SUCTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank nd/or piping. ' r <br /> Facility Name: <br /> Add <br /> v �l <br /> ress: City: Zi p: <br /> Phone #: <br /> Date Tank Re <br /> ceed: —(� <br /> Signa 1 Gam/ Title: <br /> iii�i♦•• ii/aiii•. iiallaaalaaii►aaaiiifaii►iiiaia iii li♦aa iaiaatlliii♦rata ataiaiiiiaaaiiiiai►ia►laaiii <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />