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I <br /> E�ul l KaL cel [ �pG : yWoL(76Y� IW- <br /> UNDERGROUND S RAGE TANK DISPOSITION TRACKING RECORD SIDI Lam( t �t� <br /> •z»xrxatarttx i' responsible <br /> #*rttttrSECTION I - Public Health Serving Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returnlic Health Services within 30 days of acceptance of the tank by the disposal or <br /> recycling facility. The�ppermit holdfor ensuring that this form is completed and returned <br /> FACILITY NAME: ArQ SCC- `50Z-1_ 5Z:;k-- KTP <br /> FACILITY ADDRESS: Z3eao rt. r--- Ic4±AM 1A&LL7-i <br /> TANK ID #39 - >(S i (843 Z Tank Description: LOQ iWL ;WeQ . <br /> ltiriitiiii iYiiti itt iittiitii}ii tit ti#}tii##tiritii iiiiti*ttY»ii*t*}*}*»t#}}t}}t#iota}it***itl"i iliiii it}tt <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: hR t n G(1 LC��1z It 16 <br /> Address: 117_`17 Gf>L-OMA, 7 City: FAPAC14 (42S r Rip: <br /> Phone #: I(v 0 Date Tank Removed: <br /> i it itYtiiti tt Yttattttiaaf ti}itii#itra Yii Yitf RY*tttiiiilitiili tr4ilat Rtii#ri ai!!!»}**itratrittiiitiiYi <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #: (� <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Signature: Title: <br /> s+**rx*isiiil»raasararrraxrasiax+saa»+*»»x»rlsrxis*t}irsrsri#a:xaaa#x#»******iaiiiaasa»#»lixrasst tt:a*++**r <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone #: (� <br /> Date Tank Received: <br /> Signature: Title: <br /> ++staaaarra##»}}sssrttalarsslr»sat+r:ria}*»rrr*!!•araaarrr*r+rsasliarsrar•*rlrarar*s!alaa»srrtr rrtxrs:rr <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />