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0 0 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />••..•••.•••••••••••••••.••••••.•••••••....•••••••••••••••,•.,,••••••....•,..•..•••..•...•.•••.••••.•.•...•. <br />SMMON 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_ <br />FACQ,PIY <br />TANK ID #39 -.0546 - Q I <br />Tank Description:___1 O COD Cag�. STS t_ <br />................................................................................................... <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />Address: "2ji=(o3 G <br />City:. MtUZR44- Zip:__13(o�F� <br />Phone M: �G�—L ��P ( _gyp l <br />Date Tank Removed; <br />............................................................................. •,,....,.......•........•.•.•• <br />SEC ON 3 - To be filled out by contractor *decontaminating tank*: <br />Tank Deconteminatlon Contractor. QA t A.AA r o. <br />Cit: zip: 13638 <br />Phone *: <br />Authorized nepreseeRtattve of contractor certifying through signature below that the tank has been decontaminated in an <br />RPProved manner M rWtrireQ.by Cal EPA <br />Signature: <br />........................................................................................................... <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 -___M <br />City:)_— Zip; !] l <br />Phone #: <br />EN B 049 (Revised 7-10-92) <br />Peas 10 <br />lJ <br />