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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ..•..••....•......,.,•......too......•,,......••.........•..•.....,.....•..••..,.........•...••..••......•• SECTION I - 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 enstiring that this form is completed and returned. FACILITY NAME: ICJAX Radio Transmitter FACILITY ADDRESS: Harding way 1/4—mile west of Bever Lane, TANK ID #39 - LSi$ q Tank Description: 1000—gallon diesel fuel storage tank ......a............................................:................... ....,............,...............,. SECTION 2 - To be filled out by tank removal contractor: SEMCO Tank Removal Contractor: Address: 1217 South 7th Street City: Modesto Zio:95351 Phone #: 2( 09 524-9653 Date Tank Removed: SECTION 3 - To be filled out by contractor 'dewntaminating tank': SElQCO Tank Decontamination Contractor. Address: 1217 South 7th Street City: Modesto Zip: 95351 Phone #: 2( 09 ) 524-9653 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA Signature: Title: ........................................................................................................... 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: A & S Pletals Address: 1616 Angelo Pray City: Modesto Zip: 95351 Phone #: 2( 09 1 537-4766 Date Tank Received: Signature: Title: ..................................t....................................... .,........1................... EH 23 049 (Revised 7.10-92) Rage 10