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/ UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> iRitiiit#i tiY4Yt4it#ilii!}Y4iYt#!till!#f Y44tl Y!#ff itt4f!#flift!?ti#tt}tYt#ffi#tiitf}#ti#tti}ffti Yt##itlttik <br /> SECTION I - 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 <br /> FACILITY ADDRESS: 2167, A—E M{Q&I <br /> TANK ID #39 - Tank Description: /x-56 (� ► / �`' �,.�' ��� <br /> iiiitiili44#i}#iiltkii4iYt44k#ii441k}Vik4iYlY4lkltYYt4ll4Yk#Yl4ftlitflft!#kl4Ykf#Yf li Yi#4Yf#YY##Yll YY44Ytt4 <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: TOr --C�t-4�� ialrrd' � ' <br /> Address: ,?& /VJ© �•{,�a,Tl �r • City: 'rn: c Zip:9�'�7_LJC'�- <br /> Ph 'E 4(K!44--9 .one #: caDate Tank Removed: <br /> 4-'� ##i##4#4t!##fW#iW}fkif#if#}Ri##tW##twit#kt4kt!#ii#tttiti#tY4Yi##Yikt#}tfW##ti#f YWkf i#4tl##ll#it##Yttkit#!t! <br /> SECTION 3 - To be filled out by contractor "decontaminati g tank": �, <br /> Tank Decontamination Contractor: �z'c rani r��f ST��19d {C <br /> Address: S� (/C [.Ll4a ) S' City Zip: <br /> Phone #: 1�—W ) � !R'= <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: <br /> Title: <br /> 44ii}#i!##k##i##4i4#it4}k#flit#kk4}}t#Y##k#4k4#fit!#Yf#444#44#if4}k4##R##i!##t!#YR4#}f#kk#fitf4#i4 <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:y <br /> Address: <- 1120G�2�7 City: 24DGl�— Zip: <br /> Phone #: (—Ap <br /> Date Tank Received: <br /> Title: <br /> Signature: <br /> }##4#4##i##4}#Yt#i#4ii4##4#k4#fif#fit4####k44#t4k#f#4i##t4####Yt##l##t##kf##tY4i 4iit4#Y34Y##4!!#tR}it##t## <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />