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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 -Public Health Services io P�g Health Services withit will accompany n 30 days oh tank f acceped tance of theth its site tankby `the disposal or <br />tion number - <br />The Tracking Sheet is to be return <br />recvclins facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />1. <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />+ ' i0 <br />TANK ID #39 - Tank Description: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: !(Lavf-/iz-At1 r <br />CitY: E fC- Zip: q �� <br />Address: O <br />Phone #: (___) ( S Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Citv: Zip: <br />Address: <br />Phone #: L___—) <br />hrough signature below that the tank has been decontaminated in an <br />Authorized representative of contractor certifying t <br />approved manner as required by Cal EPA. <br />Title: <br />Signature: <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 />City: Zip' <br />Address: <br />Phone #: <br />Date Tank Received: <br />Title: <br />Signature: <br />EN 23 049 (Revised 7-10-92) <br />Page 10 <br />