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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />iY#Y#i###Y#i#t#Y##i#ii#####YYii#t###tit####itkti#tiY#ikit#Y##i#####i#Yt#YY#ilYiiYiYi#ii#ik#ii##t##YY#iYitii <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 responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: Qul)k ;;W, O <br />FACILITY ADDRESS: 9. .J / A 2 . '27, A I"/, I /D„/ -<J-- P , / ._ l <br />TANK ID #39. � /- c-,/ Tank Description: Si dk4- w <br />�— Pulnll�S (4— <br />#####YYiiiRYYYt!##iYili#YY##Yi##i!#####t###############s#t###!######],�#�s#.#s#�s####sss######s#is#s##s###ts#### <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: GtrI'lk r- 0 �,� F/jG <br />Address: J�. �. 6 b X j /s city: G -,Roo e n 7" <br />2av � zip:yS 6' 6 � <br />Phone #:c( 719 ) G S.5 - .3 / 8/ Date Tank Removed: <br />#i!i#!!t#itlY#!t#iii!!i###tt!!i!#ittttt!•ttttlRiitii♦tttttitttltYtt#t!t#t#iitltt#tt#t#tltt#t�t#!###ttti!#t# <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Wilk u l ha . -Z n G. <br />Address: YO, d, 6 d XPIC aS41.7 T <br />/S 0 City: 6-g o v r zip: 95-K6 8 <br />Phone #: (9/� )_ 6 S S - -3181 <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 />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: _ R 121 e. �C- S b y-, <br />Address: _ t 57,5- eQ l2. p- E t y a City: 2 rl inn a vA � zip: 9 d/ <br />Phone #: (SIO a 3 S- /3 %3 <br />Date Tank Received: <br />Signature: Title: <br />EH 23 049 (Revised 7-10-92) Page 10 <br />