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0 I ohm <br />UNDERGROUND STORAGE TANK DISI'OSI I'ION 'TRACItING RECORI) <br />flltlt}ttttltlftftftfltfttftff!!!ftlffffflf tltfllfflfltftt♦lftfftffltttftf t11t1fftltttf ltttf 1t/1ltfftf llf t! <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 dnjs of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: (l,� 1-k It - ., �_'' '� 1J'n. #* - ` f I Y\'�'_ �/��NJ. `� <br />1 <br />FACILITY ADDRESS: <br />/ J _ <br />TANK ID #39 �y2 l0 '� ' Tank Description: <br />lttt tf ttt!!ltftltit}tfttt}f♦111!!!t1lllflftlflf llt tf It♦•t/f!ltftfltl♦tltf/f•lf ttftllltlllftf t♦llffflff/f•1• <br />SECTION 2 - To be filled o 1 by tank rsrn_q%ji contractor: <br />Tank Removal Contractor: (L`' ,� F t { i e 1,t 4'`V" <br />Address: 1�.I� �,- X._ Y).Q✓-� `9� _ City: -r -1i` zip:�� <br />-- <br />Phone #: (Ty) � ,�, I - I (' 1% 10) Datc 'Tank Removed: <br />1f111ttltlttl•♦t11•tflttltflfttf!ltllttf�t���f ltltlt♦Itt111ftfltlfltftf♦♦lf tt ltltll!♦fff llltt•tlf •ltll•fflf <br />SECTION 3 - To be filled out by contra for 'decontaminating tank": <br />Tank Decontamination Contractor:_ i <br />Address: >L> ►� �'(- Q�iy i. _ City: r-) Y-\ zip: (.l <br />Phone #: .� 61 �,�— � '- ,�) <br />Authorized representative of contractor certifying through signature below that the tank has been decont iminated in an <br />approved mannerciufred by Cal EPA. <br />Signature: <br />!1!!!t!!1tlt!}t!ltttt•!t!}t!t!t!t!lttf if lt! !11!}1111!•fltlfftlftfflfffttfttf!!fltlt tt ttfltf!•f lfffflll/1f! <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 />Facility Name: `'6A- � � )�. C <br />Address:: �- )'CM c;tyc -A--Lk� 1 i�— zip: <br />Phone #:y e - <br />Date Tank Received: <br />Signature: <br />ltftfftttfttttfttttftf•ttt!lttlflfllf sff� ���tf/lttfttll♦•tflltlflfflltlt1//l!tltf ttlftttftltfflllftlff/f <br />EH 23 049 (Revised 7-10-92) Qnge 10 <br />