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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD .s.rsaos..r.s.ata.s...ssa.as.saaaasaaa.sasaasaasasssasaasaas»ssaa+.asu....*aaaa......++a............. SECTION 1 - Public Health Services Tracking Sheer will aceompany each tank afrxed with Us site identification number. The Tracking Sheet is to be returned to Public Health Service within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this,formm is completed and returned. FACILITY NAME HOc-yo q y- U,(\OUQviro, StZ�lbr1 �X23 FACILITY ADDRESS: I O 3y L oi(A Ag � CA TANK ID #39 - Tank Description: %iao - 5-sy -5aKarl USI S aa...a.asaass.r.s.....a.ar....a.a.r........aasra.............aar..aaaa.........•.........asaaa.......oz SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: v Address: City: Zip: Phone #: (_� Date Tank Removed- a.a.....r•.a.aaa s.a.a.a axa.zss aaa.as sasaxaasa sagas-sa•aaaa.aa.u...a.a......aaa..asaa..aa..uasas SECPION 3 - To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: Address: v Ciry: Zip: 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: r rassra.ra.a•••.•+a.azaaaasas.z.aax.azursaszraaxssrsasasxaraaasraa a..lot aaa auar.rr.aa.a...ra.x.... SECTION 4 - To be signed and dated by an authorized representative of the treatment,storage, or disposal !`aciliry accepting tank and/or piping. Facility Name: v Address: City. Zip: Phone #: ( Date Tank Received: Signature: Title: ..............aa...a.........s............................aaaa raa+as+r sag aaa aaaaaar•araaraarr.r.. EH 23 049 (Revised 7-10-921 Page 10 6 -d W02i� Wb l£° l l 9661-50-L