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SAN • t HEALTHSIVICES <br />I. • ► HEALTH <br />DIVISION <br />UNDERGROUND • ` A DISPOSITION TRACMG RECORD <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and retuined. <br />FACILITY NAME: FL -M t �-1 Upas ► r,.)G - <br />FACILITY ADDRESS: (fie' l�"�"� , ��` ` 1�2¢� <br />TANK ID #39 - TANK SIZE: I D, 00 O PREVIOUS TANK CONTENTS: VNtrc +�J�ro CCAS <br />r� L f- 0Aj <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:r� <br />Address: Q % O 1:�, ? City: -Ws e c Zip: <br />Phone #: ( f c ) -3 7 25 "' Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: ,{I INC. <br />Address: J <br />:� I o Z S City: W • `�,�=t �` Zip:: <br />Phone #: (� 1 (o ) 3 P! i — i i 4st5 <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. <br />Name: <br />Title: Signature: Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />FaciliryName: wES"t' <br />Address: <br />15 \,A). LI/VW®0® City: "T'1.C7CK, Zip: �53® <br />Phone #: ()9sj <br />Date Tank Received: <br />;dame: Title: Signature: <br />Date <br />rt esrtwrtrt*rt*rtrtrtrt*wok �prtrtaert�rtre:a.:rt*rtArtsrr*rtrtart�rtrtw�.�..rtrtreeols yaartysar+¢+��rt�*ab ws.srtrtrtrtrt*rtrt*rt�rswrt*rtrt*rtreertrt*:rtrtrtrt�k �krtrt*rtart�r <br />EH 23 046 (Revised 7/10/96) Page 10 <br />