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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> assaasasasssstiasaaaasaa»atasiaaslsittiiiasaaastasasttastasasattiassiaa+ss>tact;asasasaiaaiiaxalasasaxlxsas <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: aZ2) ©2-4LH <br /> FACILITY ADDRESS: <br /> TANK ID #39 - !ZZ?�� �� Tank Description:_12,000 Gallon single wall steel <br /> >xsw»aslixls;lsass»accts+sat>stal++;stsaatslaasssassa>saxlaiist>+assa>;tiaxli>iiys!>xitalixss!>ax;ta>a+i+x <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. Advanced Environtnental Services Inc. <br /> Address: 1419 North Market Blvd. , Suite 5 City:Sacramento tip: 95834-0457 <br /> Phone #: 9( 16 ) 928-8300 Date Tank Removed: <br /> x»wa»x+wxwtaww>+ia>a»;x»ww:.a+aswts+axx»>wwwa>axa+sxws>ws>sxawt>+•w»»ws+»»awawaww»xswt>i+aw>»ww+;»»ww++ <br /> SECTION 3 - To be filled out by contractor'decontaminating tank": � _ n� �b <br /> Tank Decontamination Contractor. Advanced Environmental Servi.es Inc. 1 <br /> Address: 1419 North Market Blvd. , Suite 5 City Sacramento Zip: g9si4-0457 <br /> Phone #: ( 916 ) 928-8300 <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 /> +wi>xaii>xft>laai>xxxii;alfaxliiia»tiifiia>iilt+ifitt+itiiifatifatiiiiiliitlti;itxi;;ai>;tiii;>;>aliiixiixx <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting mnk and/or piping. <br /> Facility Name: ��//��O/✓ cy- Q r� <br /> Address: �O�j 2) LUJ Lp,: J �)1 � <br /> . �t� aity �(n,,c 6+,U6 Zip: ! RO Z _ <br /> Phone #: <br /> Date Tank Received: <br /> Signature: Title: <br /> •>aaawsalss+»wan+xssa>stxws>»+xslsassssaaa+a+a:+s»aalsasss!lissss!>tslsssaasxalasalis>axlx>ia>sas+ssswws <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />