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• <br />L <br />UNDERGROUND WrORAGE TAMC DISPOSITION TRACIaNG RECORD <br />.••♦�atiiiitiNit{{Ni!lil/iNHlHi4NlHlH�l111!!1�llNiN!lNlNiliii{i{ii{{�titlNttiisii�aa���•�.„. <br />SECTION 1 - Public Health-Sefvim Tre6idag Shm will awmWy each bulk afte i with tic cite Identification numt-c , <br />'11►e Tracking Sheet is to be rejW40 to Publlc Health Sq*M rithln 30 dare of A=ptance of the tank by the dispot--41 <br />►cycling facility. The ponalt hOMW 16 reipoacibjcr bf MudanR,thit t11ic forte R cotnpteted and returned. <br />FACILITY NAME: iii e--A—C aL <br />FACILITY ADDRESS: /� � 1Vg4=� �!E � �src�-ice � f — <br />A 4 Iw r 7 • euf,l�r r <br />TANK ID #39 - l l , TV* Dcactip G�C,� La-La'J <br />tion:.., rl-Y �; .t <br />....••s•s�s�at�tstt{tti{{!{i!i{iii!•!!liiitliiiliili!liii�!{{•{•{{ti{itt{{{{••{{t{ttti�t��•��•••••�••••••+ <br />5L(: TION 2 - To be filled out by too rwnogtracwr, <br />Tank Removal Contractor: 'F-r)f I c f- -S c� -_ ) C - • - <br />Address: zip:-t <br />Phone #: IR :5 S _ Dato Tank ROMC' ai: <br />...�••r►••t�����••tttt{{i{{{ii{iiiiiii{{i!!!iliililii!•�!i{!i{{{{{ii!{{t{•{••�{is•tt•t����•�•••••••••••••- <br />5L(:rION 3 - To be filled Got by Colltractor'decoatataiaagag tank': <br />Tank Decontamination C0a4&4;Wi: <br />Address' <:22C`J 1.1.i�+1'i•��.. ,i•r,e•-rr•r-- Cltr C M�J Zip: ` <br />Phone #: (�C'1CP) ( / e7 A•+, :•i! ! <br />Authorized reptese 4ativq-coateaCug *Mugh dSttatura below that the tank his been decontaminated in .a, <br />ap )ruved an er by Cal EPAJ -- -- -_ .----- - <br />Signature: - Title:' . 44-A. <br />.«.«.��•�••it•tttisiiittitii{{{ifilii{{{{{ii{{lit{{{•t1{i{{tit{{{{{{{{{{��{{••{���si•t���••••••««•«••+... .. <br />sL:'LMON 4 - To be signed and dated by &a authorind rapertatatagra of 11110 treatment, storage, or disposal facility <br />accepting tank audlar piping. <br />a l CoaS� t <br />Facility Name: � ----�•j- <br />Wdress: 5 L• am �. Y ?gyp: _ C_ q(�=• �U O <br />Date Tank Received: <br />-- :.,:• �•. t • + Title: - - <br />signature: ,� ,.�. �....�..r • un i hnrli m <br />•��•a���ttssitt+/{{i{{{{!{!liiliii!!!!!i{i!i!!i!i!!i!!!!i!i!!{iliil�li{{{{{{{•{{s{t►sis�{s����s•••�«..•. <br />EM <br />�1Ya 10 <br />23 049 (alvised 7-19-99) <br />