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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 enstiring that this form is completed and returned. <br /> FACILITY NAME: K ZNX Trarlst+nti fer <br /> FACILITY ADDRESS: FVay cLknR V�e, Wei% L tt�i<ysP �t r n W t� �e ypr �atv� e <br /> TANK M #39 - N/P, C Tank Description: t000 �AL[0 r atcSel :p t k cin-raw- im,kk <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: <br /> City: Zip; <br /> Phone #: ( Date Tank Removed: <br /> ........................................................................................................... <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor. <br /> Address: City: Zip: <br /> Phone #: (� <br /> Authorized representative of contractor certir)ing through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Signature: Title: <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 /> Address: City: Zip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title; <br /> EH 23 049 (Revised 7-10.92) Pepe 10 <br />