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0 0 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />ssstasxrgstaats ttsat Ratttaaasaraassstasrtaatsatattssaaa sstsuattrsatsstttsststtsssttxtrtxrta raaststtt>satt <br />SECTION 1 - Public Health Ser,ices 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 NAME: 'r -L_LL - `7T0c' 70p4 <br />FACILITY ADDRESS:_ 40S[ / � <br />TANK ID #39 - I F- l 06 - )� Tank Description: [VIMV UN Uso.( or,7 C,d�Llb it3 id��1< <br />tsars•arstit»sstaasrsrstu.rr.rsass s•es»sas s>sra..rssrssaa asassass.x.asrtt•r.♦•sssssss.st... r.ra rtssrt. <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 />.>stttr.sissttttiirtttt.tta...........aa.r.a..t>rr>rt..t.aa.ts.>.at.t.rta t,.. a a s. t t. t... a........ r. a r t rt <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 />Signature: Title: <br />s»arstttsrsrttsststttastttrsusustsstst.sstatatsiisrtapsstt.tars»ststtrstsstgattrarrrttrsssttssststtt <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 />City -_Zip: <br />Phone #: <br />Date Tank <br />Signature- Title: <br />RttttttttlRitttttttttftttttttllftttltRlitRttttitlttittiittltlitlf tttlttttttittftitittttttltti ttsttltttlR <br />EH 23 049 (Revised 7-10-92) Page 10 <br />