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4 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />####i#iitii######ii#iiiiittttttt #iittttii iitt#tt##ti###iii#iii###ii##ttt#iiitti#i#t#i#ii##i#ttt##ttifit#i#2 <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: <br />FACILITY ADDRESS: <br />TANK ID #39 - Tank Description: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: City: Zip: <br />Phone #:( 1 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: <br />City: Zip: <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 />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: <br />Address: <br />Phone #: (�_ <br />Date Tank Received: <br />Signature: <br />EH 23 049 (Revised 7-10-92) Page 10 <br />City: <br />Title: <br />Zip: <br />