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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />■„Iasi/,atttts■ttattttatttetattatffsttt■ii■taat,ttai/sats,■sigt,tt/tttttt■■f ittattttt, ittaat <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank aff Ked 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 NAME 3A1 102 ST1QTiO/J <br />FACILITY ADDRESS: -3011 kj ,IVU J A -KA 1 rJ A4W, M-1 t) C3". `5TOC KMA) <br />TANK ID #39 - <br />Tank Description: <br />ttt,,,tttrrt■it itttti,tt,i,titttittrM t,tatttttatiti,atrtfst//a■iiatt,ttta tttt Mt/ttfi/tt/atMtttttt <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 />.........■.,..a■■st.a..,Y,.,.,at..art....a.......■.,,.,,./s.a...■.ra...■.■.■........,sat.■....,..,. <br />SECTION 3 - To be filled out by contractor'decontammatin tank': <br />Tank Decontamination Contractor G may .4' �V-V-� -rN(f , <br />Address: B !�j A `t: V11i SMk-er- City. n i>!i.i4f(l Zip: 796Z I <br />Phone #: ( 510) <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 />Signature: Title: <br />l tttatttftttitt titaatitltitif iitlttitttikittaitififlHtitiftR}}iiiktiiti t}}itttititftttiaaitiif iif ttt <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 />r <br />Address: Z.S-�S' PARF, City: RIGlmonil, zip: 94801 <br />Phone #:S( ID) Z S 3 q 3 <br />Date Tank <br />Signature: Title: <br />,ttr ltaaultaatttl, ssrssaatl tsassss:aitass„stssssssatatsttas,aass iiaaltsss■, tsaastisast <br />EH 23 049 (Revised 7-10-92) Page 10 <br />