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U <br />• <br />UNDERGROUND STORAGE TANK DISPOSITION 'TRACKING RI;COM) <br />f!ltftttlttttfltltttttt!lltttftlffl!lttttttttttlltt!!lf tftllt!!t♦♦ttllstl/t1lltftNt.4tt/t4ttltltlNNltN/ <br />SECTION t - 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 days of acceptance of the tank by the disposal or <br />recycling facility. The permit holder Is responsible for ensuting that this form is completed and returned. <br />FACILITY NAME:i ` i J "� �� (, 1 <br />FACILI-TYADDRESS:��' �, (;.�. 1j"j1—tn'V 4f.r'L0r�� <br />TANK 1D #39 - Z-1 2'1b Tank Description:_ J % <br />f1f/!f!f!!f}!1lffll!}ttf}f}}tfffttft!!t!t!1!.ltttttRt...ft!lt4ttltll4 tltttt!!ttltttt!l.f.l1lt. tf ltf!lllttt/ <br />SECUON 2 - To be filled o�� by .tank rcmoval contractor: <br />Tank Removal Contractor: �i ►,° .,�'-t%f� `Pl i �' �__..�i11���M�_i1��P ��, /.J--��r --- <br />Address: e i-) �J>'y `1, �jQ✓� City:-_ � r� Zi 1) <br />Phone #: i Tom)T�; - j ►t j �? �� _ Datc 'Tank Removed: <br />t1l.lt!!!!!ff!!!tflf lttlf!!!!f♦♦!•111!•tt.t..!!4♦lr.14.tl.rltll4.lt..rt.♦..►t!♦.Ift•♦•fIt♦t.ltt4l t.tl.t.Rlt <br />SECTION 3 - To be filled out by conttafFt "decontnn--T-A1-1:) <br />inating innk": <br />Tank Decontamination Contractor: l .ti i � i_. >° - t"1`i) � f 1 i ,ti'►, *t,\ i ii Y t ►►r,. ► Y 10 ti'? - %l `. <br />Address:_. v i ). t Z; ' {- �'��`� —1 - -- _ City:zip: <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manners required by Cal VA. „ I <br />--41 <br />!flttttrttJlttttfttlNt}ttllttttf ttltttttlt!!tt♦!tltf <br />♦!1ltt1lflt!ltttltRf!!ttlt!!tllt!!11lf!!tlflt!!lltt! <br />SECTION 4 - To be signed and dated by an nuthorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility <br />Address: zip: <br />Phone #: <br />Date Tank Received: (� / 4 — <br />Signature: <br />tlftftttf !f tlttlfft :! f!!tf!!ltft ftfltt!!t4♦ttftt!!t1!►1tlt!!♦t1.!♦tt♦ttll!l111ft/t.!!!l1/t111/tt1f. <br />EN 23 049 (Revised 7-10-92) PAge 10 <br />