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UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD <br />•u•uuuu..ou.ouuo....r............... u.....u..... s.r.... r• r......... a ........ .a....... uu..... <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 3o days of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned <br />1- I <br />FACILITY <br />FACILITY ADDRESS: �% S <br />TANK ID ,.39 - Tank Description:U U C� <br />........................................................................................................... <br />SECTION 2 - To be filled out by <br />Tank Removal Contractor_r <br />removal contractor. <br />City. Zip: <br />Phone #: (_� Date Tank Removed <br />................................... ...................................................... :................. <br />SECTION 3 . To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. <br />Cirv: 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: <br />Title: <br />..uru•uuuouu* .ur..0 u. uru.uuuro•ro.u...uuw <br />...........................r........u..... <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 />Fatality Na <br />Address: <br />Phone #:( <br />Date Tank <br />City.. <br />Signature: <br />Title. <br />M <br />.....uu.•.. .................. I...u.u.•r... u. a r........ o u u u.... u. u. u....... a u..•...... u.r <br />ER 23 049 (Revised 7-10-92) Page 10 <br />