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1%W <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />rt;rau;a,sgYtat>stN♦};»a>rr»s};•sy„i!;}tiaa�,s;rtaii,issr»>,ssaaa}}sii it rrsatirr}i•rsiiitrrsr rr raif} <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 />FACIL=NAME: 1,1677 l//CLO-I irk <br />FACILITY ADDRESS: e. . Arprl-t UO/g - Gl oofV 1crI, 6� <br />TANK ID #39 - Tank Description: 116D6 Li / /V U5f <br />tarsaYrrfisitarr;f•rr»tt••errs„Tfi;tr»asssi;f,Bars,staff}rlsiaaraali;a»rta}tl;sa a�}f»rs}Tsi;>»isu,ti•t <br />SECTION 2 - To be filled out�by tank removal co9tractor: <br />Tank Removal Contractor:_ <br />Address: 15157 (6-1j'%l °j Dr -1 City: G Zip: q57— <br />Phone #: L19 j �j�,�' �� h� Date Tank Removed: <br />}a;aarff»ar}f»reif•Yrirp sffrrrrr>•raftr•asaiss,raii•,,,arrraaarff,aaaa}rrtf r•»„rrirar!}aaaaarrarrff,f, <br />SECTION 3 - To be filled out by coutractor 'decontaminating tank”: <br />Phone #: �/[ iy, ” ' <br />Zip: W` c / <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 />Title: <br />liragirrittiY}}}f tarriit}iiitiafi,ifii; Yf,rts�i�tfislHH>f btrtta}tMitafai};i ttb gliitrsr}}f}ft;f}ttfti <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 <br />Address: 5�5 'orr �1 V, City: I ' Zip: �%F <br />h( <br />Phone #: LQLJ J 5- oq5 <br />Date Tank <br />Title: <br />•,rs;:,r♦i>t••s•atistTtasif srr•s}sats•rtsat„ftas•,is;s,ts».>tt„ss,!}s,a;rl,a;;rf; iasrai:. •.•••„}}•;> <br />EH 23 049 (Revised 7-10-92) Page 10 <br />