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UN ROUND TANK DISPOSITION TRAC G RECORD <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification <br /> number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by th <br /> disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: Lawrence Livermore National Laboratory (LLNL) __________________________ <br /> FACILITY ADDRESS: Corral Hollow Road, Tracy, California <br /> TANK ID #39-1945-22 Tank Description: 4000-gallon capacity,single-walled.FRP tank <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor LLNL <br /> Address: Corral Hollow Road City: Tracy State: California <br /> Phone#:( 510 ) 423-4881 Date Tank Removed:_ <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: N/A <br /> Address: _ City: _ State: Zip: _ <br /> Phone 4-( ) <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated it <br /> an approved <br /> manner as required by Cal/EPA. <br /> Signature: _ Title, <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 /> THE TANK IS TO BE CUT UP TO PREVENT RE-USE. <br /> Facility Name: _ <br /> Address: City: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Signature: _ Title: <br /> EH 23 049(Revised 7/10/92) <br /> CLOSURE PLAN: 865-D1U1 <br />