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y <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />=a=aa»»ae=s»a»aa»ea»»sasses»»»»ease»a»aaeaa=a=aaa=a»sae»aaaaa»ae»=ea»aaa=a»aa=»:ass=a»se=a»»=asps=sae=a=ease <br />ch <br />nk afted with <br />ts <br />cation number. <br />SECTION I - Public Health Services <br />ervi ed to Public Health Semrvices wianti�in i ®da of acceptance 1 of site <br />thei tank by the disposal or <br />The Tracking Sheet is to be terata <br />onsible for ensuring that this form is completed and returned. <br />recycling facility- The permit holder is resp <br />FACILITY NAME: <br />til 1,10 <br />FACILITY ADDRESS: 2-'1 W M <br />TANK ID #39 - <br />Tank Description: 10Cooi ivY+ �� �—, <br />a=s»==a=e»=s=mms=a=»»mma=:sea=ass=s»�as�=sassasassasaa»=»=ass»»seas»amm=s»saaaaaaassess»=s==ass=asamm==s==a»aas <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />Cites. gyp' <br />Address: <br />Phone #: (� Date Tank Removed: <br />ease=aa=sass»�a��=mma■»»sass»»sea=a»aa===sas�sasa=»aaa»eases»ammmmaea=a==mm=ss===mm=aaa=aa=ea=se=��as=sammaa==a»s <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. <br />City: �P= <br />Address: <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 />Title - <br />Signature: <br />aaa=ease=»sss»sa=aasea=»»»»sss=sea=ss=aa=a»ass»=s»seas=»:=seas»ssaaa�sge»ss=s»=sass»»aa===sasses=sea»=sss=as <br />rized representative of the treatment, storage, or disposal facility <br />SECTION 4 - To be signed and dated by an autho <br />accepting tank and/or piping. <br />Facility Name - <br />City: Zip' <br />Address: <br />Phone #: <br />Date Tank Received: <br />Title: <br />Signature: <br />a»=aa=as===esseaea=aeaea»=aaaaa=e»aa»a==easasses=aaa=a===a=aaa=s=ee=aaaaa=aaaaammae»aaaaa=»:»sasses»ease» <br />-IH 23 049 (Revised 7-10-92) <br />Page 10 <br />