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UNDERGROUND Sroi2AGE TANK DISPOSI HON TRACKING RECORD <br />!!lftttstttlf•ttltlttttltt!lttt!lttt.trrrtrtrt+rt+rt+:rttlr!!t!+ltrt!lttrlrl!!tflrtrtr!l+tr.ltttrtt.t.+rl+• <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 Service within 30 dajs 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 />FACILITY ADDRESS: i_� , �i ;. I 1 )�W t . :1ii �r�`I.1. i�. t? r <br />TANK ID #39 - 11-1Z <br />' -62 Tank Description: I -1 j(Y_ iP.1�J. s __ 1J'. f �'� - 1 �;1;�� i ;ALX- <br />!tlt+ftlt!!!!flttrtttfttf*ttf♦tlt/r+.ett!!!l+rrlrrtt+.+tlr++r+!!:rlfrrtrrrr•rstfrl.r++.++.t!l.rrlrttrt.tr+♦ <br />SECTION 2 - To be filled o�}� by tank mmovil contractor: t <br />Tank Removal Contractor: iv(1.,� x �(� e1,1i1��. ��.1yyf)r we}l�� lt,_(,_ <br />Address: ii _> • =U �- �.t� 11 ! — City:_�J - ` 1 ` Zip:"�: %_ ! j1 a _ <br />Phone #: (�. (�'1) ,�, j - i t j 0 ) DDatc 'Tank Removed: <br />.tt♦tt+tttfttttttfr+rtttt«ftrlt•ts:+..t..+rt.rrt+e+.++t++t.r+.+lttrr.+r.+.r.+.r.t+r.+.t.r.+r++.+tt+.t..ttr. <br />SECTION 3 - To be Filled out by contra or "decontnnkinating tank": t <br />Tank Decontamination Contractor: <br />Address: U 1 City: `J j)f tir Zip: <br />Phone #: ! �f �1) ��.���' 622> ----- <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner as required by Cal EPA. <br />Signa <br />�7 <br />!ftl11ltl�,�tyf!`ltttf tt!!1!!lttttltlNtttflt <br />/tttltf+#•t!!♦tt!!1tltlrt!!•/rtlt!!lt/rttt trltrlr.tl t. ttrtttlt <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•_ <br />Address:_,— -tcZ-- 1 (,),CYlC Y" �L'i . City: i L�jF� l zip: <br />Phone #: <br />Date Tank <br />Signature: <br />lttttttt.l <br />EN 23 049 (Revised 7-10-92) <br />i <br />Page 10 <br />0 <br />K <br />