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UNDERGROUND STORAGE TANK DISPOSITIONMkCIUNIG RECORD <br /> SECTION 1 - Public Health Services Tracidng 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 dM of acL,+tance 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: Com <br /> FACILITY ADDRF-SS:-422Z-;L���Z—C 1<�r=� P, <br /> TANK ID #39 - Tank Description: <br /> SECTION 2 - To be rilled out by tank removal Mcoctor: <br /> - / A <br /> Tank Removal Contractor. <br /> Address: y City: <br /> Zi p: <br /> Phone #: r ate Tank Removed:___ <br /> SECTION 3 - To be filled out by contractor odecontaminating tank": <br /> Tank DecontaminationContractor:— <br /> Address:----&-Q­6�, �C"( Citi: K , zip:_,_ <br /> Phone #: <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 at by an authorized repmsentative of the treatment, storage, or disposal facility <br /> accepting to and/or piping. <br /> Facility Name: "Fr. 0 -5'fir"rayllleel/_a <br /> Address: Zip: <br /> Phone #: LILL) &(7 1 <br /> Date Tank Re <br /> Signatu <br /> EN 23 049 (Revised 7-10-92) Page 10 <br />