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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> +arrarrrrrxaxartara+aatr+astaaaa++»attaraaasa+assaraasssssartasasaatr»aisaii♦•sssraaaassaaaxisitataata+++ <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: Jit�/L114 �CCGKiNC���/1/C <br /> FACILITY ADDRESS: <br /> TANK ID #39 -�6� ^� Tank Description: 13 ���G� c�A6uwV DIESEL <br /> •rxrrasrastar+ara++a+rrrx+arwwrasaastatxssrsuttwysssraratiars+attaaaxsxassrtarxs�rxsrsstay•x+rara++rw+r+xxr <br /> SECTION 2 - To be filled out by tank emoval contractor: <br /> Tank Removal Contractor: Eil+Gly <br /> Address:—/71 0 �r lL�f�O1 �2E�7 City: Zip: / <br /> Phone #: c 7105 ) l27 /6�3 Date Tank Removed: <br /> •+ra+ar+asattsasataastr•ssattta+s+sr+rr+assasarsaa+xsatarrsasxsar++xisssrtsttaasaatsaraxaa ixsr♦rt rx xxrr err+ <br /> SECTION 3 - To be filled out by contractor :Oecontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: /Z/a- 5, ??�/ City: /06QES7p Zip: � ✓S/ <br /> Phone #: 7( Or ) 5'P� <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 /> rrarrra+satssaataaxsaatsaaisar♦+aa+sxs wasasiassas++tat+++itaaasss+ssaati•+tea+ia+rttaai++xawsaatxa+s+xxr•a+ <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: 407 C <br /> i <br /> Address: ,/ �l2�� �`� tEer City: Zip: ?W0 <br /> Phone #: ( 1'D ) ?'3(0 X006 <br /> Date Tank Received: <br /> Signature: Title: <br /> •ur»t+aaaar+aa•eta♦+aasia•asaai»taaa+•asartitraas+assaars-sassssia+aasasiasarasaa+s»rsrt+sxsa+ra++asx <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />