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STORAGE TANK DISPOSITION TRACEUNG RECORD <br />SECTION 1 - Public Health Services Tracking 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 days of acceptance 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 <br />FACILITY ADDRESS: <br />TANK ID #39 - Tank <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />Address: City Zip: <br />Phone #: ( Date Tank Removed: <br />SECTION 3 - To be filled out by contractor 'decontaminating tank*: <br />Tank Decontamination Contractor. <br />City.. <br />Phone #: <br />Zip: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved maturer 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 #:(� <br />Date Tank Received: <br />Title: <br />ER 23 049 (Revised 7-10-92) Page 10 <br />