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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> 4itititt}trYiYR#gttiigrrt Rtt#gtttti RiitYgtRHttt R!#ritttt Httttittttttttt}+Yip ttt#Y tlt ttYtR+rtt tttt#+i <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 NAME: iar (� LC <br /> FACILITY ADDRESS:—Iff(3 kn <br /> �Wrlwn S&tP�_0 LLC�10n <br /> TANK ID #39 - D Tank Description: Die,<Ce <br /> iii##«rrtiirirrt«#•itirrrisl+!«•iiriir#«4+4t+Y+rrrrtt4!#+•irrri•tiltl•rrrat••RtwwurrtrtttittptrrttsiitirR <br /> SECTION 2 - To be filled out byy,tank r movalntrvor: p <br /> Tank Removal Contractor: /lSre� n (JrncC( <br /> Address: �7-M Alam t i (lif- A Pwarp'i ` tllir k _ city: <6n PaMOA_ zip: <br /> Phone #: ( .la i 997-381Date Tank Removed: <br /> liVti VY#itlttlp#!#kiiii#lilt#i#!#i#tr+Ytiitt#iitR!}4 ti Vti Yitiitt Mtrr}rtititttliYtt NfrttRittttirin##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 /> Signature: Title: <br /> #ii#Yr###SR#4t!!+iltYi!#####!4#1++t+iii Yikt####}444RiR#+iYiiY#ti!!!##+t}•Yrrti!#Rt!###lr4rVY}tett!}}}!f#}#} <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: Ert&Sm(� /� <br /> Address: SCC Parr LS J City: Rtr" M61 U Zip: <br /> Phone #: (� <br /> Date Tank Received: <br /> Signature: Title: <br /> 4irtirt}###}4t###til++tirtiri#ittR4t}}!t#iti########iiiirt RiR}t!#4}44r4titYit##til}RRltittr#riR#####iiR ixs# <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />