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v v Ert�/tP�W�acC4-L ccs-lT 'j�y�No,1.06Y� t� UNDERGROUND S RAGE TANK DISPOSITION TRACKING RECORD ttitif itlliif iif iixllfittti+ttt>af if tt>itf»xaai>i»iiixiiaiti»fiiififitxii>iittf atfiiiiiattii„a+,>lf axafifi SECTION 1 - Public Health Services cking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be return o Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit hold ' responsible for ensuring that this form is completed and returned FACILITY NAME: Till J=CL 'u'8 L_ 572X 1C-7TZVJ FACILITY ADDRESS: Z3� IA/\.LL-2� P-9-co 4,mo GAt1oN ti-r2e - TANK ID #39 - /E°ig3 - I Tank Description: t *.....»*.a.xx,sx..>.i.i>*.,.aai......**..........**.**...six..a.x.s....+axis.a.ixias.»x............. SECTION 2 - To be filled out by tank removal contractor. Tank Removal Contractor: /�2oe,�.E7,j ✓nt�tti i�6'.tLln16 Address: f(7 IT (AC-oW ,4 fz.t7 City: RAl4c'}y 6rtRV0V1$ip: Phone #: &10 --3 2,1 • I tP45C O Date Tank Removed: .*,.>..i..,,...,i,i...a*,i,..........*..i................>....f„**.,>„>f„i.>f.>.....*.................. . SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor- Address: ontractorAddress: City: 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: SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: Address: City: Zip: Phone #: ( Date Tank Received: Signature: Title: .il.itxs+!lsssia>.iisi*•+.si!lYi+a.st»i»lilt+salt*+.>a..a+..s.a>Yfitt>Ys+.ssaf+>.»tst+.aas>tss.sit!>t!. EN 23 049 (Revised 7-10-92) Page 10