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UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD <br /> / iYtasssarsrsriaaaaarsarlatlraalarias:!!q»a»rssrriarrilasiYaaaslaralaaraasaar!»tataa»ssasais»!!s»ssiY <br /> 'J 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 /> OFACIL=NAME: <br /> ©FACILITY ADDRESS: //�� <br /> ©TANK ID #39 - Tank DescriptionM <br /> i sYYsararsrgatsartriiYtraaas•sass»isssssaaaa»tririY»aalsaitiiraaalaiirr!•aaataii•sltraass»rrriraiiirta: <br /> V SECTION 2 - To be filled =by tank removal contractor: <br /> Tank Removal Contractor <br /> v <br /> 17l 1 Address: Ci <br /> V®✓Phone #: (_� Date Tank Removed: <br /> %sstrirttattatatttariiiiittrrtrYrtatisarrsrraa tarasssYswtrtasaslaart»rimttasassssstiasiriYtt»aaaarrttti <br /> SECTION 3 - To be filled out by con�te/Vr "decontaminating tank': <br /> Tank Decontamination Contractor, <br /> ©Address: Ci Zit#1 ) <br /> & <br /> IY Yhone #: (� <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 /> ltsstas»arasassssaartit Yiili»sisaaarii!!slltrrrriirli»rtratYitatiaalrala»a!ltrrtttiraaaisiirriiariasiri <br /> SECTION 4 -To be signed gn and dated by an authorized representative of the treatment, storage, or disposal facility <br /> y� accepting tank�an or paiping. <br /> fY g''acility Name: <br /> Address: City: Zip: <br /> hone #: ( <br /> &ate Tank Received: <br /> Signature: Title: <br /> riritttttltittiitiiiiiittiiiittttiiiatliiifltftftltftiiiliil•ttlfifiiistiirrirriltfltt!litittilYttittiit <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />