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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> r.ar.•uurs•au aaursrrxarrxs-rru.ux....xxra•xxaur ur.u.ru uxsura usss.xx+.sr..u.ssrx s•rxsxuura u• <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 NAME: Chevron U.S.A <br /> FACILITY ADDRESS: 3775 Tracy Blvd. <br /> TANK ID #39 - Tank Description: 12,000gal U.G Fuel Storage <br /> ......rr urr ra•.•uruxru++arts...r.....rsxwrrax..r..surrxrr•.sua..r•ur r.+..rr+.r u......•a............. <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: C4 L t F 0 K fJ1 R P ET2n t-Eu✓A <br /> Address: City: ZIP: <br /> Phone #: (_ Date Tank Removed: <br /> ............r..u••rs.•u♦••r..•x............................w....x...........rr.............rru.......... <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: ERt C 5011 <br /> Address: 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 /> Sienaiure: Title: <br /> uau.rx.r Nrxxasruxsrr•+r.+x.s.ru•.•rut.rruuu uuuu.uauusrut,rsr.r.ux.ru.rusa•ur•u•ru.r.x <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: -61,eoroyk—US-A— j!�Iele-Ksdw ///C, <br /> Address: City: Tracy Zip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title: <br /> .......................ar..................................a♦u.uuuu•..,...a.............x...r...... <br /> ER 23 049 (Revised 7-10.92) Pase 10 <br />