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UNDERGROUND STORAGE TANS DISPOSITION TRACKING RECORD .. a.... a.......ur.............................................v................ a... a..... a 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 recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACM= FACILITY TANK ID #39 - Tank Description- i C'C' ............•uu........ou..........•.......................a............. .............................. SECTION 3 - To be filled out by tank removal contractor. Tank Removal Contractor._ , 7 t)✓�� I�h� �� Address: Iv lenNol �w.Ce IC I:: I(� Cirr. T✓ '- Zip: q�37�-�`�,S I Phone #: ( "I� O - I Z 3% Date Tank Removed.�g71 7� I I 1c, q S ........................................................................................................... SECTION 3 - To be filled out by contractor "decontaminating ank Tank Decontamination Contracror vl l r� l G td`s �N4Lr m�� n 1 & uu ^' Address: ��Z Z� ✓1n rr� (,� �i 1 �r ,'i City Zip: Phone #: (L I ) j- � -� "0 � --" Authorized representative of contractor certifying through signature below that the tank has been decontaminated in as approved manner as required by Cal EPA. Signature Title: ........ moo ..................................1....1".t.....1......................f..f..........i.i......... SECTION 4 - To be signed and dated by an authorized representative of the treaornent, storage, or disposal facility acmlpting tank and/or piping. Faciliry Name.- R N&(Z v tarK.- 27 I I N A t_ l�r Clry: 5-�t/64j,✓ amp: Phone #: ( 2-O q I q `I 9^ 2 Date Tank Revived: Signature: Title: ........................................................................................................ IN 23 049 (Revised 7-10-92) Page 10