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16. <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .............iiifi,ifi,f„iif,lft,ti„ifiififiiiiftttll,iitfftitiiiitiftillii.....iifililititfftlif i,,,i.i♦ <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed 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 /> reeicling facility. The permit holder is responsible for ensuring that this form is completed and retumed- <br /> FACILITY NAS: P4vt4crtom �Ao2 dAK L,—A/T( io, <br /> FACILITY ADDRESS: 1000 E . C,14AA1146L 5T Sroc roa G,4 <br /> TANK iD :39 - 1OLl r-1 -D l Tank Description: 1000 &ALLA 4U kEdy S EN6 <br /> ................,............i...a,..•..............i,......,i,..,.,............................i........... <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: '56w-0 <br /> Address: (Z!1 WA SI". City. MOt)ESTO Zip: <br /> Phone 1-: ( Zely-J, Date Tank Removed: Fg13 ; I tl lli <br /> ......,............,...i...............i.ii...ii...,.....,v..,.,,,................,-....................... <br /> SECTION 3 - To be filled out by contactor "decontaminating tank": <br /> Tank Decontamination Contractor: �dilCl� <br /> Address: (V 1 S . -7* City: Di�56STo zip: as�iS <br /> Phone ': SZy <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved mann as required by Cal EPA. <br /> Signature: Title- <br /> ...........a..............................................a................,.,,,.,....a.................. <br /> SECTION 1 -To be signed and dated by an authorized representative of the treatment, storage, or disposal faczliry <br /> accepting tank and/or piping. <br /> Faciliry Name: <,/'J mAer 0k, c <br /> Address 140 7 "1fk Sr. City MC 1 zip: C[J 2✓J -- <br /> Phone #: L22�Ln sz2- N3S <br /> Date Tank Received: II <br /> signature- ( �Z l �) / Title- <br /> ......................................................f.....,........................................... <br /> EH Z3 049 (Revised 7-10-92) Page is <br />