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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD I <br />. jymil QIMM <br />-aneK t e Isposa or <br />recycling facility. Ile permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME, (julyk— <br />TANK ID #39 - Tank Description: �3i t--� CA UP—� uj 4-c.A-- F-t2-P;hf <br />SECTION 2 - To be fliled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: City: Zip: <br />Phone #: Date Tank Removed: <br />SECTION 3 - To be fliled 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 />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. V I K' rD <br />Facility Name: <br />Address: City: <br />Phone #: <br />Date Tank Received: <br />Signature: Title: <br />EN 23 049 (Revised 7-10-92) Page 10 <br />Zip: <br />