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—ac. 5569 <br /> \#/ l./ <br /> PIPING ONLY <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> f#raa>rrritw###44!•rf:##a4a>w##>!#rlOrr#ii###»#!»l4ix#rxwra##»trrx#iiwiix!#x!4»##4w#aa#aw#rw#aw4»!#>!4#awa• <br /> SECTION I - 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 NAME: ARCO Facility 5569 <br /> FACILITY ADDRESS: 3518 E. Hammer Lane <br /> TANK ID #39 - Tank Description: Piping Onl <br /> #to#ix!#tt#at##>4#f#>fa4wl4it#4i4#aura 4r#4fx#it}a>!#r#af#i!##t#Ort#law#i>}a!4!#4a##>!!>ta>444#!##4#a>#>4#!# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City. Zip: <br /> Phone #: (_) Date Tank Removed: <br /> #fw#rwrr»#rr#4t!#awira#r##wr#r!#r»#}>»#»#ri#iifiwr#rx#rt!i»#ira#i#+rt##w»ir#r!#r###alta#a#4f###r>!»w4»#i»#i>! <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 /> Title: <br /> Signature: <br /> }!w!»}ai#>!##a#a#4#t#aw#a4>a4li#rifiwT#3#ia#»»#at#r#a>4rw#iw#Y}#x###}x#}!i#w#a#4a>#a#rwltt4t#a!#44a#tw#t##! <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 /> Title: <br /> Signature: <br /> t}4:##aa4rra#ta#w#tx!}a#4»#x}}x4#wxr##rwfi#a#xxfi>xrlarrtxlax#xxfir#!x##x#ix##»4i:ra#}xa4r:»#r##4!#a4#4#r!#> <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />