COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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11 ROUND STORAGE TANK DISPOSI"1'lON 'TRACKING RECOitI) ##t###!##!#!!#!##!##!#!!#!###!#!!#t!!1#tt/t!t«#tttltt«#ttt#tt!lttt#tt!!tt#! t t## t t!! t t#! t t l t t t t!!#t!!#tltt SECTION t - Publ Ilealth Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sh t is to be returned to Public Stealth Services within 30 dnys of acceptance of the tank by the disposal or recycling facilit . The permit holder Is responsible for ensuring that this form is completed and returned. FACILITY AME: ai5! " =1 '��C ��. �` f � �, �J h = -�f �'i `K Aj FACILITI ADDRESS:-/--' i__'7' (j"I �,a,i .i.�� y�d� 1Y, I � "Y' '( . 4 J , TANK ID #39 - Tank Description: I -1 sg YJ ��: �J' r _ p �7 It;f d t �Yl x I I'LL SECTION 2 - To be filled otu$ by tank rmoval contractor: Tank Removal Contractor:. � _1 i ��._ � � 't 1�`�_ �4�.�ta�_�i��P t�_ 0 Address: City: Zip: Phone #: ,''� - j jl _ Date 'Tank Removed- * * 6 * * * * * 0 0 * 0 0 * * * * # * 0 * * 0 * * 0 * * 0 * * # 0 0 0 * * # 0 * * * * * * 6 * * * 0 * * t * 0 # * * I # * 0 # * I * * * # * * * * * * * 0 * * * * # * * * * 0 0 # # & * * * 0 * 4 emoved: t!#ttltt#####!#!!#!#t##•!!######!tltt#t#tt«#!!!!####t#♦#ttt#1!##!##!####!!#tltt#tttt♦!!0##!##t##1 tt/t###### SECTION 3 - To be filled out by contrator_"dccontnn�hmling tlnk": Tank Decontamination Contractor: > �., 'r -A `6 Address: { )- t - .� ----- ----- C'�ty: � _1 f Y`. Zi Phone #: (2t' L �62_Z --- — Authorized representative of contractor certifying through Signature below that the, tank has been decontaminated in an approved manner as required by Cal EPA. Signature: 'Iitle: t SECTION 4 - To be signed and dated by an nuthorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: t, Address:—' t 0, j1 ��' — City: --a Zip: Phone #: ( 1 Date Tank Received: Signatu Title: EH 23 049 (Revised 7-10-92) page 10 # 00