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uNr <br /> GROUND TANK DISPOSITION TRA G RECORD <br /> M rrtrrtrwrrrrrrtwr»wrrrwwrwrrwrw1W wrtrtrwrwwwwrwwrwwrwwwwwwwrtrtwrtrrtrtwrtwr rtartrrrwwwwswwwrrtrwwwrwwrwwrrrtrrrw. <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(LLNL1 <br /> FACILITY ADDRESS: Corral Hollow Road, Tracy. CaLfomja <br /> TANK ID#39-)"1`-F:5— 829-21WLTank Description: 27- on paci ,smgs-walled.carbon-steel ank <br /> frtwrtrtwrtwrrwrtrrtwwrrwrwrtrrwwrtwrlwrtwwwrrwrwrrr»wwrwrrwrrwrwrrrrwrtwrrtwwwrtwrrrrwwwrtwwwrtwrw»wrrrwrtrwrwrwwwww4wr. <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: LLNL <br /> Address: Corral Hollow Road City: locy State: ('alifornia Zip: <br /> --Pham#:( 510) 42-14881 Date Tank Removed:_ <br /> »rwwrr»r»r»rwwrtwrrrrrrwrrrrrwrwrrrrr»»r»rrwrrww»rrwrwwwrrrw»wrwwwrrrrwwwwwrrrwrwwrrtrtrwwrrt»wrwrwwwrrwwrwww. <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor. N/A <br /> Address: _ City: _ State: Zip: <br /> Phone# <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 /> »»»»wwr»•wrwrrwwr»wwrwwwwrwr»w»r»rr»»»r»r»»»»w»»»r»»»rw»r»»»»»»rrrrwrrwrw»»wrrtrr»w»»»w»»w»»»r»»wwrwrrwwwr. <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 /> Facility Name: Lawrence Livermore National Laboratory <br /> Address: Corral Hollow Road City: Tracy Zip: 94550 <br /> Phone#: 510 ) 423-4881 <br /> Date Tank Received: <br /> Signature: Title <br /> EH 23 049(Revised 7/10/92) <br /> 10 <br />