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UNDE RGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affted with its site Identification number. <br />'Me Trackine Sheet is to be returned to Piblic.46%, Nr�xYL=yff",T 4—v <br />• r i' i.' tr I i 1•.:. 1 ♦ - r • Yi !: • i :.; I - r r -C <br />FACILITY NAME: <br />FACMITY ADDRFSS: <br />T - 11.11& -�®7- `®) Tank Description: <br />SECTION To be filled out by • • •; <br />Tank Removal Contractor: <br />Address: City: <br />Zip: <br />Phone #: Date TankRemoved: <br />SECMON 3 - To be filled out by contractor 'decontaminating tank": <br />Tank Decontamination .a • <br />Address: City: is <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: <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting r • piping. <br />Facility Name: <br />Address: City: Zip: <br />Phone #: <br />Date Tank Received: <br />Signature: Title: <br />EH 23 049 (Revised 7-10-92) Page 10 <br />is 0 <br />