COMPLIANCE INFO_1995 - Laserfiche WebLink

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�j n rx• ••, r • r + t t ••r as#asst==ffi#!sslisis#lmmsmmsris#siffismmssslsass!mmsssrs=simmissmmiffiiffisrs#t!#�ss�ssmms!#mmsssffis##ss##!s!mm#ss=mmiffi#asses SECTION I - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recyciing facility. The permit holder is responsible for ensuring that this form is completed and returned. FACII= NAME: U rJ oP,A- L- 'r--' FACILITY ADDRESS: 2,-101v✓ '�-L-^ l-^ " '"' �'�' TANK ID #39 - Tank Description: s#ss#asffiisls#ss#smmsrsmmrssasrlsssrls!#ssississmm#sass#mm#ssrs=sssmm!#rmmssmmsass##�ss!ffi#mmssrs##mss##ass#sssssrass SECTION 2 - To be filled out by tank removal contractor - Tank Removal Contractor,. Address: City: Zip: Phone #: ( Date Tank Removed: .. armmsrrrrrrsrasmmmmsssrsssmmsrrrsssrrrrsrssssarsrrsrsrrrsrrmmsrrrrsrsrssrsrssrssrsrssrsrrsrrrsmmsrsssrrrrrrrrssrs SECTION 3 - To be filled out by contractor 'decontaminating tank': Tank Decontamination Contractor. Address: City: Zip: Phone #:( Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Signature: Title: #!mm#rmmffiffi:!mmffimmmmli=mmlislsmmrmmmmmmmmimmmm!=mmiiirr==+s#=ra==ii====i==a===#=#=====mm=#=r===rr=mm===#=a===r=====mmr=#==s==mm SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: Cirv: Zip: Phone #: (_,� Date Tank Received: Signature: Title- sass:smmisssasmmss#ssssmm#sssissleasels!#sslrmmssssssmmsssrssssmmssssssssssssssssmmsssssssmmsmmsssssmmssslapmmsmmlmmsmm ,EH 23 049 (Revised 7-10-92) Page 10