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i UNDERGROUND STORAGE TANS DISPOSITION TRACKING RECORD .......,•..a,a•a.ar.•,.,.ass•a.•,.>..aaa,..,a...a..>ar„r ars.,.aa.aaaaaasasa.a.a.a SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAS: ?s"vtL-rl&m CA4 &/Z L4pmrex- FAC>L17YADDRESS: (000 E . b4AN46L 5-r Srncewu .LLG4 TANK IDI-39 - Tank Description: 1000 &AtWN F-tlC 56rA1 F ......a,aaa......a.....rv>...a,a.aa.,a••rrr.a,a,a.,a.a,>a..,araa.>raara,...•a.a,a........ SECTION Z - To be filled our by tank removal contractor: Tank Removal Contractor: U5UMO Address: (Z1? 5 . 774 SF. City. P00E5TO Zip: 4s'sl Phone ( 2M ) 5Z-q-10*31 Date Tank Removed: F9 tell< I.............>........a......a..,,a•a..s..........a•........,,,a r..,,.......aa..ra,..•aara,.a. SECTION 3 -To be filled out by contractor "decontaminating tank': Tank DecoDecontamination Contractor: 1� t Address: (7,11 S • 2* 2 - City d�7 i 0 Zip: Phone �: ( ) SZq Authorized repres ntative of contractor certifying through signature below that the tank has been decontaminated in an approved mann as required by Cal EPA Signature:- Title: .......... .............................................................................r..........,,..,.. SECnON 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. j� J 1 Facility Name: deS M JWJV-k 61A p Address: Phone #: Date Tank Received: f signature: Title: ...............................a>........,...................... ....,...>as.aa,aaraa,aa.aa EH 23 049 (Revised 7-10-92) Page 10