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./ a/ <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> sssrssasrsrsssssssrsrsrrrrssssssrrrrssrr»rasrrlstoolsiressrrrlsstassasssstssrsrssslsassss!lsasslssssssassss <br /> SECTION 1 - Public Health Services Tracldng 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 /> ible for enstiring that this form is completed and returned. <br /> recycling facility. The permit holder is respons <br /> FACILITY NAME: SH6t T, RX Cc. <br /> FACILITY ADDRESS: /D W4N� <br /> 71! 7! <br /> TANK M #39 - !� fie/' G Tank Description: 2 T cl�•• c� S Seca�r� <br /> asrssss!!slsrsssaarsssassssassrlssrtrasrrrrssrrrsararasrtrasrstesrrorasrrrasrsrsssasssrs!lsarsassrsssssrlss <br /> SECTION Z - To be filled out by tank removal contractor: rC ZC <br /> Tank Removal Contractor. EN Z�is 0� <br /> City: AG _Zip: <br /> Address: / —&C <br /> Date Tank Removed: �d <br /> Phone #: <br /> too sssasrasrssraasrlslssasrsrssassrssasarsosasslrrsrsssssorrrrwaartorrsrrrssslrssssrasslssrssarsarsrlssrss! <br /> SECTION 3 -To be filled out by contractor 'decontaminating tank': / C % S <br /> Tank Decontamination Contracton- <br /> Address: /?6/ Lt <br /> Ciry: 7- -*6 Zip: 7,41 <br /> Phone ar4 <br /> Authorized representative of contractor certifying through signature below that the tank hasbeendecontaminatedAL'&E— <br /> approved manner as rcqg by Cal EP <br /> Signature: <br /> rriisiislwisol ass irrlrsifs!•se»» rassrsaarlrrlarrrlarrrrra.Rsralarrtaslssrasr»a sst•as r!!liriarrr!lf ss rlrar! <br /> SECTION 4 - To be signed and dated by an authorized reprzsentatire aC the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: 1 R.'-- 4rU L <br /> Address: 35 Z S 5--Z � City . ' .rJTd gip: 9 <br /> Phone #: ( ) Z1` Iq 11 <br /> Date Tank R=Wa l v — 2 4" <br /> Title: r�7V <br /> Signal <br /> s»ssssrsaslsassssssssrslsssrlsassasaawsrssss»sasrsarrrsasrrasa»ssrrass■tarwosssssarwrtsrssesrssrssrsss»■ <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />