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• <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />dentification number. <br />SECTION i -Public Health Services Tracking c Health Services accompany <br />each <br />o days of <br />cceptance ®f ed with its site <br />thel tank by the disposal or <br />The Tracking Sheet is to be returned to Public <br />for ensuring that this form is completed and returned. <br />recycling facility. The permit holder is responsible <br />FACILITY NAME: U a �A a® g a Le <br />FACILITY ADDRESS: <br />TANK ID #39 - Tank Description: 12 <br />SECTION Z - To be filled out by tank removal contractor: <br />Tank Removal Contractor. <br />City: gyp' <br />Address: <br />Phone #: (, Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tanks: <br />Tank Decontamination Contractor. <br />City: �P <br />Address: <br />Phone : r certifying through signature below that the tank has been decontaminated in an <br />Authorized representative of contracto <br />approved manner as required by Cal EPA. <br />Title: ' <br />Signature: <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 />Ciry: gyp' <br />Address: <br />Phone #: <br />Date Tank Received: <br />Title: <br />Signature: <br />Page 10 <br />.EH 23 049 (Revised 7-10-92) <br />