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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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: <br /> FACILITY ADDRESS: <br /> TANK ID #39 - Tank Description: <br /> siiiss»fattttisr•istiiw•••sistwssisaitatsssststsssratterrstsiitsirrrssattissaitstit Ytssssssssiatsisiw• <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. <br /> Address: City:_Zip: <br /> Phone #: Date Tank Removed: <br /> tissssstastastsssssrtratas#ssssrisisssasis»ttria»ssttsst»asaasssrrsais#sssrassastsatiaaississssisiisatsa <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 /> #ti#ia##i#ttiiit}i}4}###iY#it}iiiiitiila M###iii}4#iii#i#iYYa##iYYfi#####i###i##ia##iait}#}#}i#tiiti}tY}f}ik <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: <br /> Address: City:- Zip: <br /> Phone #: (� <br /> Date Tank Received: <br /> Signature: Title: <br /> sislraitttisii»risaisiittstitssitsisssiasastlrisstssittiiittrriatsr�assitrassrsarraarss»ttissrarissr <br /> EN 23 049 (Revised 7-10-92) Page 10 <br />