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UNDE&OUND TANK DISPOSITION TRA NG RECORD **:****+:.•.**ss:•s****•s•os*•�*:s:•.a**.*•.«•*sss•s•s••.•*••*ss...**•*«••*•*«*.sss.••••*••*ssos.•****ss*» SECTION 1 -Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: Lawrence Livermore National Laboratory(LLNU FACILITY ADDRESS::/CnrW HAIIOw Road.Tracy.CaLi_fornia TANK ID #39 - U7® Tank Description: 99110 c cily.single-walled.carbon-steel tank *+.*.****«*:****:.•«a*s.*•*s***«**�****�****•*«*•:ss*•s***s«:s:.s*«****«*::**•s**s.:.*•*****s*«*.********� SECTION 2-To be filled out by tank removal contractor. Tank Removal Contractor. LLNL Address: Corral Hollow Road City: Tracy State: California Zip: Phone #: ( 510 , 423-4881 Date Tank Removed:_ *•******•s�***.*«***•s*s******�**«***********r**ss***s***s•*****•**«***s**:s********:**•�*****s**.*�*****: SECTION 3-To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: N/A Address: City: State: Zip: Phone #: l ) Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal/EPA. Signature: Title: **ss**r..s**s*•*s�**a*****«**«*�**m+*�*+aa**�•sr*s•**.•*s**••**s•*:*••s*s+ss.«*w*�*.r**•**«**ra*arr**a�****+ SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility accepting tank and/or piping. Facility Name: Lawrence Livermore National Laboratory Address: Corral Hollow Road City: Tracy Zip: 94550 Phone#: ( 510 ) 423-4881 Date Tank Received: Signature: Title: EH 23 049(Revised 7/10/92) 10