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UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD !!!!!.......alaafa...I.................*.......xxaaxa.....*......iiia..!a!!.!!lxle......*....... SECTION 1 - Public Health Semces Tracking Sheer will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 39 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this lform miis completed and returned. FACILITY NAME POryy�g r I t\oCe ASp r J i C S lbr1 O(23 FACILITY ADDRESS: I O 3�I Q ( Lai Ave. 60 C-1:4 G/4 TANK ID #39 - Tank Description: Two - 5_S70 —q41(ar) ui5 S ass......a...............xsa....xssr.la..szY....s..s.........as......a.asx.........................aYYa.... SECTION 2 - To be filled out by rank removal contractor: Tank Removal Contractor: Address: City: Zip: Phone #: (_� Date Tank Removed: s..•!!•!♦.....•s•a.s as•saaes.asasaw.alsrsss.s.ssa.a.aa ea...e...o.u.!l.s.........l.....a!l..s•.•...as ss SECTION 3 -To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: Address: City: Zip: J Phone #: �� Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Signature: Title: ....u......a...l.•z..ulz..aus.aa.•ssaaaassa..xssaa....a.u..+..u...•!!!+.•a..l.l.la..o.l..•v uzs• SECTION S - To be signed and dated by an authorized repmsentative of the treatment,storage, or disposal Facility accepting tank and/or piping. Facility Name: J Address: City. Trp: Phone #: Date Tank Received- Signature: Title: ......a..........................................sass..aa.ax.aaxe.a.a•lYYa.ai..axl..Y.4!la..a.Y.Y.ax.xa. EN 23 049 (Revised 7-10-92) page 10 6 d Nod_ WV IE° ll 9661-SO-L