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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 ensuring that this form is completed and returned. <br /> FACILITY NAME: 501-AL `1-72 411 CC S/77�7-10A <br /> FACH-ITY ADDRESS: /0 7/ A10M29 WWII ) <br /> TANK ID #39 - Tank Description: <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 /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Coontractor. C�L'J—T <br /> Address: 4 } A � a� '-i City: rW".r _ Zip: q962-1 <br /> — <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 /> #i##aA#iiii#ii#*##*####i#ii#i#iiii:ii:t##i#*###ii#ii##ii##iii#i#is#ttiiii#i#i#i##ii#SFr####i##kkk#1'iii#1ii##4 <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: QI c'� rJ <br /> Address: Z- � + ti��� � City- r�Ir Mkj10 Zip: TiRC11 <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title: <br /> EH Z3 049 (Revised 7-10-92) Page 10 <br />