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' UND VWROUND TANK DISPOSITION TRACIMP RECORD <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification <br /> number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by th <br /> disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: Lawrence Livermore National Laboratory(LLNL) __________________________ <br /> FACILITY ADDRESS: Corral Hollow Road, Tracy, California <br /> TANKID #39- j® ,12Z Tank Description: 1 Ila on ca�a�ty,single-walled,carbon-steel tank <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor LLNL <br /> Address: Corral Hollow Road City: Tracy State: California <br /> Prone#: 42,1M1 Date Tank Removed: <br /> }rtrtrt}}rt}}}rtrtrtrtrtrt}}rtrt}rt}rt}}}}}rt}}}rt}}}rtrt}rt}}F}}}rt}rt}}}}}}Frt}aP}}rt}}rt}rt}}}F}}rtrtrt}}}rtrtrt}}rt}}}}}}}rtrt}rtet}rtrt4}}}y <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor. N/A <br /> Address: _ City: _ State: Zip: <br /> Phone#:( ) <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated it <br /> an approved <br /> manner as required by Cal/EPA. <br /> Signature: Title: <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 /> Address- City. Zip: <br /> Phone#:( D <br /> Date Tank Received: <br /> Signature: Title: <br /> }DF+trt}}}rt,F}+Frt+F+F}rt}}rtrteFrtrtrt}rt+F}rt+Frtrtrt+F+Frtrt}}}}rtrt}F}}rt+F}eF eF}rtrt}}rtrt}rtrt}rtetrtrtF Frtrtrtrtrtrtrtrt}}'F eFrtrtrt}rtFrtrtrtrt}aF,F@iF}ei}rt}}iF}rtq <br /> EH 23 049(Revised 7/10/92) <br /> CLOSURE PLAN: 834-DlUl <br />