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UNDERGROUND TANK DISPOSITION TRACKING RECORD s•r•rw•w.,•♦•.rrHr.wrf r,f,Hsf.,«,w1.s•,•.rrsf,.��ffRfssw.ffr,R,sf rs„srf,l,ssf•f,a•.,.,,f•feel rf•s,as,f SECTION 1 -Public Health Services Tracking Shat will accompany each tank affixed with its site identification number. The Tracking Shat is to be retuned to Public Health Services within 30 does of acceptance of the tank by the disposal or recycling facility. The permit bolder is responsible for ensuring that this form is completed and returned. FAC LM NAME: L&w=nMJjvemore National �boratory Sitz 300 FACILITY ADDRESS:,&M 'L7 lr Q sa r.�.., r nlifornia TANK ID #39 - , `t 2 "2 Tank Description: Sit lid'. nglalled.carbon-erect tank ..«ssfR•s«..,.:„:,.««.w•w«•.,••s•..ss•.sR.,..•,s•«s«s•.s...s.:sews•«•,.ss«sR.s.::ssss«s•.,s.•,..ws«.s.«,f SECTION 2-To be filled out by tank removal contractor. Tank Removal Contractor Address:325 ZOMM 1.w a L. 5T city: ►:�1r State: Zip: — Phone #: (40$ 1 4�� I�$`� Date Tank Retrnoved _a c�7 f x'13 SECTION 3-To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: Address: City: State: Zip: Phone #: ( 1 Authorized representative of contractor certifying through signature below that the tank has been decontarnbuted in an approved manner as required by Cal/EPA. S Tide: ..ss.,•...«..•.ss..Rr•..ss•.,w«.sss.ss«ss«•s:•s:w•sss«.ss.s•s.ssssss:ss»ss»sss•sssss»++sssss.s•+:r.s.s.sss SECTION 4-To be signed and dated by an authafted representative of the treatmesit,storage.or disposal facility i accepting tank and/or piping. Facility Name: Address: City: Zip: Phone#: Date Tank Received. Signature: Title: ..s,sRs••.....•,..ss.s.s.«...s.....s.«.s.s.ss«s.s.•ss«s:s.s.ss:sR..s«s.«s.ss•ss.ss.sss..«sees••••.«:•w•.Rf EH 23 049(Revised 7/10/92) �J 10