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law Uh'DERGROUND STORAGE TANK DISPOSITION TRACKING RECORD t,t,,,iitlitttl,Itii till t... tlt,tt... ttl)l,l„ t,itli llitlti tt ttl,l a.......... tti tli ti ttltl9ltl,t ttiitt,f SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal c recycling facility. The permit holder is responsible for ensuring that this form is completed and returned, FACILITY NAME:_Co%7�r4 n S - S//�o c E �o ti �Yloivr ><en o .r C S7Lo i 7 oY, FACILITY ADDRFSS:_ / 9 %l F4cr C� arfer yj/4 y S>� C `ov G 4 TANK ID #39 - JZ? I0,5�2A Tank •tflilillili)tt)i)titi)tlfttlti tiltl)iil)tt............ittillttlt ttitttitltftii tt)t)Itlttlti 1, Iti)tt •l., t' SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor. ife -LY4 C o, eer,.�4 Address: -5-980 Z¢Sf�ee F Cit)"_..��iera�-cc.-a�O Zip: 9S—gL Z Phone #: / (o ¢ZZ _ ZG ZB Date Tank Removed: .,.i,...i.....t........t...... **.................... t................ .......................... t......... SECTION 3 - To be filled out by contractor -decontam nating tank,: Tank Decontamination Contractor. Ile rIS 74 E � eere..rq Address:_ O 7 ¢ Sf Phone #: f 9// t City:-5Ec'G-, Zip: S Z 2 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Signature: .,.....,...,iia,..., .,a a . . . a..,. a.,, an t. a....,., a ai.tl,.if,t„t it tl... .................... ..... t.,. 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: Phone #: Date Tank City: Zip: Title: ................. ............ ,..,.............. ,...... t.., ...... ...t)tl,•.......... ...,............... .. EH 23 049 (Revised 7.10-92) Paye 10