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! 1 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD , <br /> ♦r#rrrrrrrlrrrrrrr#rrrrrrrrsrrrssrrsrrrrsrrrrrrrrrrrsrrs#rrrrrri##rswrrrrrrsrr#rrrsrrr!!!!!lrrr##rr#irN!e i <br /> SL:t_110N 1 - Public Health Services Tracking Sheet will accompany cacti tank affixed with Its site Identification number. ,k <br /> ']lie Tracking Sheet is to be returned to Public Health Services W111111134 dare of acceptance of the tank by the disposal or <br /> lecycling facility. The permit holder is responsible for enstiring that this form is completed and returned. <br /> FACILITY NAME: <br /> T , <br /> FACILITY ADDRESS: — <br /> r�K 1� #39 _ / Tank Description:/— D <br /> rrirr#ir Mr♦rlirrlrir#rirrrri##iilr!#ssrrrlrrrr!#rrr#irrrrrirrrrr##ii!#rrlrrr!*###rrilrrl+*l+��!♦f!rlrr!lrl�. <br /> SP3CrI0N 2 - To be filled out by tank removal contractor: CQ r <br /> 'rank Removal ContractorAll <br /> ZD <br /> City.� <br /> Address: 7JP; <br /> Tank Removed: QSf2rr <br /> Date an <br /> Phone #: �is����� �2 <br /> •rsrarsrrssas!!rslsrssssrlssstales•srss#rsssssisssrssssssrsrsssirsssslssslsrlsssrr•slrassrs!!lsss!!+ls+l�w1 <br /> SECTION 3 -To be filled out by contractor 'decontam ting tank": 4' <br /> 'Tank Decontamination Contracto <br /> zip: <br /> Address: t� <br /> Phone #: ( ) <br /> a� <br /> Authorised representative of contractor certifying through signature below that the tank has been decontaminated In an R <br /> approved manner as required by Cal EPA. <br /> 'title: <br /> Signature: <br /> i. <br /> rsisrs+#s•srsssssrsrsrrssssiits#iiss#sisrsiisrrssssrssissr#rass#rrislisrrsrs#lsrrs!!!lrres•#�alalilslsse�r <br /> 5EMON a - To be signed and dated by an authorized representative of the treatment,storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Nanr@: <br /> � <br /> Address: — DD City: dC- Zip: <br /> Phone <br /> I?ate Tank Received: <br /> Title: <br /> Signature: <br /> irrrissr#rs!#rigs•rrrsisrassrir#irsrlisrrrs��r!lsirrr#rirsrrssssrrrr,#irisrirrsrissrrslrr#lrseis!!!rllsll• <br /> EH 23 049 (Revised 7-10-92) Pave 10 <br /> 3. <br />