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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ......................................................................................... a..... a........... SECTION I - 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 or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: / FACILITY ADDRESS: �S/S /4e)MQL ST12r-?`1- TANK ID #39 - Tank Description- 5DO QA -1c -6/\J 6A !S ..............................................................................................a.......... as SECTION 2 - To be filled out by Tank Removal Contractor. Address:—/J/5— RLi< 8"gM C)tia 6uy City: S T C K7 -O N) Phone #: ZC'13 / ti Date Tank Removed - SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor. Address: City: Zip: Phone #: U Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Signa Title: . a ................. a. s. w. a....ass..a.aa.awawa....aaaa.......wa..asasaa..a... a a a s a. a.... a aw.. a. a a a a a a a s a.. as 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: Eco c.06Y 0/y"7LC%[ /A)jOVS72[C—'s Address: 25 h�/3'72 rz BL V � City: Z (Cw4 omo zip: 14 N / Phone #: ( S 0) '7 --;L-0 6 3 Date Tank Title: .....a................................................................... w....... w..................... EH 23 049 (Revised 7-10-92) Page 10