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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rtuuertfstttf iif rifttiirtlttt lf>#titifrrus•#irstrrflas#tst#»purr#•rrltarl»s#lts rtilu sestrssptiftrt <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. Thepermitholder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: I S AnnI\) 1� Q00.� Sn 1 PIA STf M 6 n <br /> FACILITY ADDRESS: ri 1 ANCA <br /> TANK ID #39- G 503- o I Tank Description:_ 500 Cyn 0=C <br /> rttttifirtltttillrtttttttttltit#ittr#tttNsitR#raft#tttttltttR�ttf irrfltYrttirr R#i>t#lt•rttlstrttsttrttts <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: M f CC E-s %G TEc tJ n)ol oa)E�7(V I <br /> I � G <br /> Address:ca� (S"A�a11t Qf FY City: ZiP old <br /> Phone #: (� I )_ �j1} €Dn Date Tank Removed: <br /> t tittttgttt NtttttiMftttHtp N##1 ttt�tttrtttrgt#irtq•rrNs#tri•#tit♦tttrrrR#trtttittlr H•rttrttii tl#t• <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 /> Signature: Title: <br /> ittrtgitftfttft?tlftMiittttttrtilttt#Yrb#lttr>t#ltttttititgtrtittrti t#Mittrtftlt>rtr!#ttf>1gr#lt tit"♦ <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 /> FacilityName:_LFU4 7:12QON MLTA <br /> Address: ( )Q CNrr CTII U-T Aug City: 1jZ£SNO Zip: '1,2,11aq <br /> Phone #: f p70q )� _ <br /> Date Tank Received: <br /> Signature: Title: <br /> tfttitttttttttttttttttffttttttif rtit#sttitllitlif•tttlptgtt#Ritttfitrt#itHttit##f#tilt tttt#ttttttstit <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />