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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> tttY}slatxatrsYastasrasrlsiisitxis}iea ristritarersiirtetstta}a srsxaa is Ylsassltra}»sYxtaltitsrtetss»star• <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: kv%p, Ll i) <br /> FACILITY ADDRESS: W73/ Latl�b /a✓� Nah[giu� CEJ 9333Co <br /> TAINK ID #39 - Tank Description: <br /> aft}i Yxa Rtlattittatrttt YiiiititiaatR xiirfi}f aac iTa sR aittiRRtirt ti TttiRttlit}x tit ti}fitiittttiritt tttttit <br /> SECTION 2 - To be filled out bytank removal contractor: <br /> Tank Removal Contractor:_ YQ11QI�� Y�/i!/if111A lf0 ZYI<J <br /> 9 brew �+ <br /> Address: city: Rip6n Zi q5 <br /> Phone #: �� g – Date Tank Removed: <br /> r:attrttripaatittiiaatti<ststsastriasttsitaitrlttttss♦a}aitlttsltttttrtt}»flit is}is tint•s srtirrxstapiiar <br /> SECTION 3 - To be filled out by contraor "decontaminating tank": <br /> Tank Decontamination Contractor: �UQIr t YC�Vn�;nn �r yyr, <br /> Address:—,M(167 �'lY 1, City: pri zip:_g5?jU(p <br /> Phone #: ( ) Lqq- 047 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved mariner as required by Cal EPA <br /> Signature: <br /> Title: <br /> iasxasstaasisarstaaatsstaasatstrsssarsxuitiiratirtt saatsaa aari}sxtssat»ssressss•aastsststasrtaasssirstats <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:_ N– ewf M <br /> Address: city: Zip: <br /> Phone #: Lga) <br /> Date Tank Received: <br /> Signature <br /> Title: <br /> itttttiHltJltitttYtttttttfittttitltiitttislatiittitrt Httttttati tiaii ttti fit!liitatRtittit}rf Nittttttt <br /> EN 23 049 (Revised 7-10-92) Page 10 <br />