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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />sass#»»#***#:*#assess***»ass***»»*»»»*»»»»*»»**»***#a***»*»»each tank affixed with its site identification number. <br />SECTION 1 - Public Health Services Trac *» <br />king Sheet will accompany <br />rackin Sheet is to be returned to Public Health Services wiitaht nhis orm 0 co pleted ands eturnedby the disposal or <br />The Tg <br />recycling facility. The permit hoiden is responsible for ensue g <br />is <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39 - } A <br />Tank Descnption: - a <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />City Zip: <br />Address: <br />Date Tank Removed: <br />Phone #: (__._� <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />City: gyp' <br />Address: <br />Phone#: (______, <br />' ed representative of contractor certifying through signature below that the tank has been decontaminated in an <br />Authorized <br />approved manner as required by Cal EPA. <br />Title: <br />Signature: <br />SECTION 4 - To be signeadnaan �o P Pin$ authorized representative of the treatment, storage, or disposal facility <br />accepting <br />Facility Name: <br />City: Zip' <br />Address• <br />Phone #: <br />Date Tank Received: <br />Title: <br />Signature: <br />Page 10 <br />EH 23 049 (Revised 7-10-92) <br />