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A&. <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany ea& tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to PublicHealth Services witjLhin <br /> 30 days of acceptance of the tank by the disposal or <br /> recycling facility. T'he permit holder Le, responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: ;j7 Z"e- <br /> TANK ID #39 - L- Tank Description: <br /> SECTION 2 - To be filled out by tank removal c!o�ctor: <br /> Tank Removal Contractor.— <br /> Address: City: <br /> Phone #: Date Tank <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address:---2-,- Cjty:---L�11� 7-ip:_, <br /> Phone #: LIL(a-3 <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 repmsen tative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: /" 4"W <br /> Address: City: Zin: <br /> Phone #: WZ 1 0 <br /> Date Tank Receiv <br /> Signat <br /> EH 23 049 (Revised 7-10-923 Page 10 <br />