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1 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />fftxifli#fY}}llttxllftf Rliiit Yit YiYtRRt YYYttltixtRtiiltllitt}!lltl lii liltiitif#Yit#!!!!tt}}t}tilttltttittt} <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 <br />TANK ID #39 - 10 DS — C- 1 Tank Description: <br />•Ytiiiltll Ylftat Rttatxttltlli lslitRtY Rr rxsi txssli Rxatitas#as#isstlra s#ra#s#irtilf itiisitiisliiliitii ti tis• <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 />............s.slala.......l...l.l.....................aa...............sYl............................. s..s <br />SECTION 3 - To be filled out by contractor 'decontaminating tank': <br />Tank Decontamination Contractor: <br />City: Zip: <br />Phone #: <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 />Tit <br />........#is.llalf....f.tt.li.t.a......................i......i...ii...s.f.... s....a.... a................... <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 />Phone #: <br />Date Tank <br />City: Zip: <br />Title: <br />•af}ttttttt Yttlltt}atfttttt»aal••tula#fffttail ufa..f ttttf sy aolllt}laaalla •af if utlttt}axs»altst»ae <br />EH 23 049 (Revised 7-10-92) Pete 10 <br />