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UNDERGROUND STORAGE TANK DISVOSI TION 'TRACKING RECORD <br />rtt!!e!t!!!!!!!!!!!!ltt:letlr!ltrrtrftfftttttltttttrfftttrtt!lttttt!ltf:tt:rlttltlrfefr!ltt/ff/tttttflf•ftt <br />SECTION L - Public Health Services Tracking Sheet will accompany ench tank affixed with its site identification number. <br />The Tracking Sheet is to be returned to Public Henith Services within 30 dnys 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:�� <br />•J 'r <br />FACILITY ADDRESS:�i�'- i_�� <br />TANK ID #39 b 6 Tank Description:_- j j ip �r) �t IJP j - I ,t;/;�� i :r Lx -J <br />!!!!!r!!!!!!!!!!t!lttrlr!!!!!t!lttttf♦•fffrlltltlRttt♦t1t♦♦ltft♦f!r!•ttttttftltlfltlltflt1t11t1/tttltf if/1• <br />SECI'ION 2 - To be filled o by tank rem_o%jl contractor: <br />Tank Removal Contractor. (I" >-'t'(C� IPuA""".A_�1Lk_AYPJO' i id /-,--L <br />Address: �.I� >. �>l� �. �Q✓i �9� — City: -fir -lr� Zip:� <br />Phonc #: (,T�) � ,�; � - j 4) I ) Datc Tank Rcmovcd: <br />ttttltftlt!!!!trltttlt!!!t!!trlt!!lt111/tttttttltttt.t♦♦tf. of ttlttttttt ltlf tt♦f ♦1t1tf /111.1•• ltt 11 t11f•♦1t <br />SI-CI'ION 3 - To be filled out by contra for'dccommninating link": <br />Tank Decontamination Contractor:�P -ijO t'1)_�1 �, .t� 1 1 p►r\ 1� }'t;`j <br />Address:_ l � L� � `� � � J� Cit y, j\ �' j � I Zi e• ��- <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner required by Cal EPA. <br />Signatu - Iitic: I _ <br />!!!!l�rr•!sl..!!!+!!t!!!!!!:.!!r:!!!ttl::....l.ltttttftlttlttttrtll!ltrtlttltltlltttttltllte♦!*tttttttt• <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: ('%&,� un `r <br />Address:. �- ►, 1� t ��-`� city: 1' t i _ zip: 'j : -�-'► I `: <br />Phone #: <br />Date Tank <br />!!!!!t!!fil�!!l4sfttltrttt}� <br />EH 23 049 V(Revised 7-10-92) <br />'Title: (� 'G <br />/tttttflutftttttft11/tttltt/♦/111t1/11e1r111/1/lltttt11t1/1111••/1/11•••/11// <br />Page 10 <br />