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v i� UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD u.v..a.a..».a.aruaa asar.aas..asaaaa.afauasasaa•aaaaasaaaaaaasaaaaaa>aaafaata.»sasyataataaa•aya.r....a SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or ree/cling facility. The permit holder is responsible for ensuring that this form is completed and returned- FACILITY NALME: l;�Da1��1 f+�lt Y�k,UPG>2 u,y�S FACILA= ADDRESS: �L$S I �. �i6�f lel[ �i1 . Loot �A q5-7go TANK IDI-39 - Tank Description: 5;b00 �DAZL�� (0A5I5 ct nl_ 9f kSe'O[, j�l pl nf� •........+...>.....aau....aa...aaa..u...aaaaa•aaaa♦.uu..uaa.aa•••a.as...•.u.aauu..+.ru•+u u...... SECTION ? - To be filled out by tank removal contracor. Tank Removal Contractor: 'iEMC O � ! Address: (Z i 7 S. `� ST City: 1 16/(�sTo Zip: 95 3 5/ Phone m: ( Zo5 Date Tank Removed: ..................a...................a..........................r..r.............a..................... SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: SCAR O Address: /L -7 C!, OI)FS-0 lip: Phone ( Le7 Authorized represe rive of contractor certifying through signature below that the tank has been decontaminated n an approved er requ'reed by Cal EPA. Signature: Title: ...............................................a..I..........................act................a........... SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name:[ ,I PbES-rV. .rdW lL ( CU419 fdY _ Address: 1q0-3 03 pw f�G_ S-r Ciry. k060`v'ro Zip: Phone Sr Date Tank Received: 1 77 signature: 1 Tide: L ..........................:.............a...................................................a........... E4 23 049 (Revised 7-10-92) Page 10