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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />ttpttpifiiNNtttlttttttttttrtMMbtiitt,i,Hil,titii Htttiitttititttttf,tttitttttittttittitttttttitittit <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 />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY <br />FACILITY <br />TANK ID#39 - �GyU -UJ Tank Description: 5 N 0'Q— <br />SECTION2 - To be filled out by tank removal contracto <br />Tank Removal Contractor: Mo t0 Sy—c �. TOA P, 7—r. <br />City: Sno I zip: ' 13777 <br />Phone #: ( 29 1 45 6 — "f C)O O Date Tank <br />tiHtH It Httt H••••tttt•H1Hirb bt,rti,t,tittt, titH•ttttttpltbt,ttt Htittb •,t•titgq MtrH tt Mtttr• <br />SECTION 3 - To be filled out by contractor "decontamin ting tank": <br />Tank Decontamination Contractor: �(1 l0 <br />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:, <br />Title: <br />tt•iiHMttittti tf ttttt•tittiititttitlttitti, titttHtit„gtttltttif♦igti Rt ititgtttlitttttltNttttiittttt <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 <br />Address: L” 1 `9 5 C"k r 2 City: 61?-5r)4D Zip: C <br />Phone #: (o --M -) 'L�J� " - J -,?-- <br />Date <br />Date Tank <br />Title: <br />riisiitpttttitttttttitttiisttrritt,stiiitiisr»t,utr,ittirt,sissitili,stl,s,tissrt,stttrsitttttttittt• <br />EH 23 049 (Revised 7-10-92) Page 10 <br />