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i 6 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ssssssassssssssssssasasssssssassssasssasaassasasssasaassss:ssssssssaasssasssssssssssasssssasssssstsssssss <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is respo-n/sible�for eamiring that this form is completed and returned. <br /> FACILITY NAME:_ RCr� <br /> FACILITY ADDRESS; <br /> TANK ID #39- r1� Tank Description:*/ <br /> 3 / �L �� � �1 <br /> ssssssasssssssssssssassssss sssssssssaaassssssasssa# s �sasss�isssasssssaasss:sslsas/s�s 4�- 4t a 6 s as gas � <br /> SECTION Z -To be filled out by tank removal contractor: <br /> Tank Removal Contractor. <br /> Address: City: Zip: <br /> Phone #: Date Tank Removed: <br /> assasssassaaaaasasassssssasssasassaaaassaaasaasasasssaaaaasaasaasassaassasassasssssssssasasssaaasasssass»a <br /> SECTION 3 -To be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor. <br /> Address: City: Zip: <br /> Phone <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: Title: <br /> sssassessssssssssssssssssassssssasssasssasasaasaasass�ssssssssassasssasssssssssssssaassssssassaasasssassasa <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: <br /> Address: City: Zip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title- <br /> sasssssssssssssssassssssssssasssasssssssss:ssssssssssssasssssasssss:sssssssassssassssssssssasasassssasss <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />