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f/ r L <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />' •w+.+ais.rrrl++.rrrti#aatla+.lailiii#rtiartrti iirt#.iwrtrtlliiiiww**llww#iii#!l!!=awl ilii/#iii*#1#li*ill#lli+##1+l <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking Shea 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: ROVAL 0A4CS," <br /> FACILITY ADDRESS: <br /> 2�f <br /> TANK 1D #39 - � Tank Description: 1*s aO Otnt i , <br /> «w...Orr.w+r+.xrrrtrt.ix.a.■aaarr#rti+++wararrtrtrrtr■iwiw+wr..#lirtrtrtiaiiiiiwwwwiwal/lii+iiswr###irti#lrrtrtrtrt#lari+ <br /> SECTION ? - To be filled out by tank reryoval contractor. <br /> Tank Removal Contractor. l [r Wti r <br /> Address: �tY Zip <br /> Phone T: (`�ILI )�4- � Date Tank Removed: 2Q <br /> wrwwwrrwar slar�rYalifirwarsllawalaalrtrt#!as=iwawwawlii#rt#lr�eilwl#s#iiii#iisiis##ss#1##wl#ll#ii s swaial=#li##il <br /> SECTION 3 - To be filled out by contractor "decontaminating tank': <br /> Tank D contamination Contractor: <br /> A s: 2 5 ,4? l � f circ �' p: 9 Z G 30 <br /> Phone #: � 5'�{� l�Dd <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: /��!.'• ? i�c�ice' <br /> ri++rr+wlsartllslrtll#iiiisiiiiiiiia=iiiwwaawwwwwswa+wwlilww#1iia#rta##iirtii#rtaawlrtlrtl#i##!i#sisiwaawlwia#ll#1 <br /> SECTION 4 - To be signed and dated by an'authorized representative of the treatment, storage, or disposaI facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City: p: <br /> Phone #: <br /> Date Tan R ived: <br /> Signature: Title: <br /> Orr=iwrw+wrriw rtlrtrtl#laiiiii+wwiiwwliwiw+rwaaaiwws#s*saasssiwasassiiaswsa*sa+ii#isiiiaw#ssslsl##iiiwsiaw <br /> "cH 23 049 (Revised 7-10-9Z) Page 70 <br /> i <br />