Laserfiche WebLink
C <br />• <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />ifffti;;liitiiiii!!!i;lofiiiifs;hittatflfsillitf/ft;itiiiiistiif;;tffffffff!!ft!!llia!!ltiiii;;isfstiisifi <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank atiixed 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 enstiring that this form is completed and returned. <br />FACILITY NAME:_ QL % L 57'o4 ���j� O / � / / / / <br />FACILITY ADDRESS: 93 a / /V , /h�,e,ti7b/� Gam! �SYn� C Yin (tet . <br />TANK ID #39 - / 7 / L� Tank Description: S4 tN �W� w A -t,4— <br />stssisasisisssssssassssifiassssss:sssslt;sssssssssss:ssssisstssssss�ssssssssssstssissssssssssfftssatttties <br />SECTION Z - To be filled out by tank removal contractor: y "' <br />Tank Removal Contractor. Gv�'/,� t rt `� Feu <br />Address: City: G/'eov 0-- Zip: 9S <br />Phone #: ( V4 ) MS'S — 3 / 8/ Date Tank Removed: <br />ssssaftsiasessssts/s♦sststsssstassrssrssaassrssassasartswrwssrswesssrssasss•sssssssissswsassss:ssasssssssss <br />SECTION 3 - To be filled out by contractor 'decontaminating tank": <br />Tank Decontamination Contractor. W rd <br />Address: 10, O, 6 OK � /S City: P6-/2 o v c T Zip: ?5C"6 8 <br />Phone #: (9/b ) 6 S S — .3 / 8 / <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 />sssts::stsssastssstss;sssssssssssssssssssssssssssesssstes!lssssassissffstssisssssssiltfsafsfslfssfs;fsisstl <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, sge, or disposal facility <br />accepting tank and/or piping. '` ^ toran� <br />Facility Name: E YZ i s �C_ S O YZ <br />Address: oZ 5 S Pct Y2 R_ 2) t�� . City: (Z r- o A � Zip: 9 a D <br />Phone #:(67/0 ) a 35- - /3 93 <br />Date Tank Received: <br />Signature: Title: <br />ssswssssstssssssssassssssssssssastsawstassssssssassssswsssssssssssstsssssssrssissssrssstsssssrsssstssss <br />EH Z3 049 (Revised 7-10-92) Paye 10 <br />