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"HYMEN C <br /> DEIVED <br /> 1 1943 <br /> 4 NTY <br /> "y PVICES <br /> DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Service Tracking Sheol will s000mpany each tank aflfzed with Its site Identification number. <br /> The Tracking Sheet is to be returned to Pubtic Health Services eititlo 30 days of acceptance o[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: !�'`L1✓L r� �� c O 11 -- <br /> TANK ID #39 - Tank Description: <br /> SECTION 2 -To be filled o4l by to remo l ntractor: _ <br /> Tank ReContrac//tor. L C -ro - <br /> moval t� <br /> Address:—26) Gly: o�c r „J zip: Yr' -Z 0 SJ <br /> Phone #: ( ZOq lam« S Date Tank Removed: --- <br /> SECTION 3 - To be filled out by contractor 'decontaa 1111ting to <br /> 'Tank Decontamination ConlractoreJro <br /> Address: <br /> C) A o (&,)l S7- <br /> Phone #: tfLq <br /> Authorized rept ante iv of contractor r ying through signature below that the tank has been decontaminated In on <br /> approved It e ` ired by-Cal SPA. <br /> --� Title:•' -�9CG5 <br /> Signature: <br /> P rized representative Of the treatment, storage, or disposal facility <br /> SECTION 4 - To be signed and dated by an autho <br /> accepting tank and/or piping. <br /> Facility Name: E=Vo -S <br /> Address: ��/C 6U� Gtr City o�c�— zip: <br /> 4�//) �w <br /> Phone #: ( e04 1 Cl —� �Z� - - <br /> Date Tank Received: -- <br /> Title: -- - <br /> Signature: r <br /> Ea 23 049 (Revised 7-10-92) Page 10 <br />