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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> RR##t;i#Ri#!#ff#ii###ift;#tffY##i;iifffiRtitittlftitiit R#;;*i#iRit R#ti#Y*#!#*##ti##i#RRiti#i;#iiiRitlt#itft <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: L�cryc-&i"', :� A T I G'�"' q y <br /> FACILITY ADDRESS: Z jC CA <br /> ,E r PSN"�G/v t � uC.I�TE !v <br /> TANK ID #39 - Tank Description: <br /> iitRi RtfttiR#R#ftltRitfttf ii Rtf titt#fitiifiiiiliRittf!#*tt#YRRiiitRtti;fittR#Yi#lYtf#tiiR##ii#iltfttt#ttR## <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 /> s*f;stsstt*Rsstss*ssssssssssssastssYsst#tssstississsfisY*t#sfstss:stsisssYssssssassitRtssttsssssisssss#stts <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <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 /> Signature: Title: <br /> itift#f!i#ttiftltffftlR!!*tftlttltf#tittitf!##sttit#ttYSRRttit#iRtliR#sR#t#tttisit ii;sssss#ifi#t#t#tRi#*fit <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: <br /> Address: City: Zip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title: <br /> ####tss#!fs#tfil;i#sis#sots#si#!s#fss*ssifs#ftisi#;##s;*;t*ftsft#*fss;t;fs###ifftti#!*i##itfsslftflis;! <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />