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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 -Public Health Services Tracking Sheet will <br />Se�� waccompiny thin 30 30 days och tank f acceped tan of theth its site tank by the disposal or <br />tion number. <br />Ile Tracking Sheet is to be returned to Public H <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: —T <br />�i1 j '1�• <br />-+ ; <br />FACILITY ADDRESS: <br />i <br />TANK ID #39 - Tank Description <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />City: Zip: <br />Address: <br />Phone #: (� <br />Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Citv: Zip' <br />Address: <br />Phone #: (_� <br />or certifying through signature below that the tank has been decontaminated in an <br />Authorized representative of contract <br />approved manner as required by Cal EPA. <br />Title: <br />Signature: <br />tative of the treatment, storage, or disposal facility <br />SECTION 4 - To be signed and dated by an authorized represen <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 />Page 10 <br />EH 23 049 (Revised 7-10-92) <br />