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0 <br />C <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />lYi!#fsltlYYl;it;;lt!!!Y!!itiY!!i»tY»oftiffflYttffYlit!!i#it#!lfifttlt!!!t!lti;tilf#t!!tt!liiifl;ii;f#!YY! <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 ensaring that this form is completed and returned. <br />FACILITY NAME:_ Qv%,k— <br />FACILITY ADDRESS: IP l �5 �n k -4 G; _ <br />TANK ID #39-17-61 ._ C Z, Tank Description: w i-Pet,Q— <br />#l;stsssis;sts;Y!lssss;lfsttsssfsttis;s»t:s:»ssaissssissssslseislti tstlss#ss#sis!lsssissssf»sass:ssRislts <br />SECTION Z - To be filled out by tank removal contractor: �T� <br />Tank Removal Contractor. Gv �'/,� t rt a • Fra . <br />Address: PO, City: C-gov C-1 Zip: FS C'� e!� 8 <br />Phone #: ( 0714 ) SSS — .3/81 Date Tank Removed: <br />ssssrst»Basilts»islssst»»isssfislessrrsasass:sssssassiisssiaseiss:rrsiiiifssesisrsssrssisssritsis:assssssrs <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. W i* Z' h C . <br />P/casa,7 7 - <br />Address: D, B o X /S City. 6-2 o v c zip: 9ScS6 8 <br />Phone #: ( 9/6, ) 65-s- — -3181 <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 />Signature: <br />Title: <br />fiY#!lfitstisit»tiffffiftftliiltfi»#s#t Rttifiiiifttlf!#tififliRfiittYitffYliflslifiiili#itiitf!!ftlttifitf# <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility s ^ <br />accepting tank and/or piping. <br />Facility Name: TE Q i c �C- S b 1'1 II p <br />Address• a S S Pc(rzR- vd . City: (� o Zip: / �f L9 D / <br />Phone #:(,57/0 ) ;2,3 S - /3 93 <br />Date Tank Received: <br />Signature: <br />Title: <br />sasiis:sssiiastsslssastfssss»siastssssssssssssssssssss:sssssss•ssistssstssssassssssssssssisssisssrssssss <br />EH 23 049 (Revised 7-10-92) Paye 10 <br />