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Jul.lu. LUUII 5: 31Vft1 SLMGu IIL Lvov f <br />SAl AQUIN COUNTY PUBLIC HEALTH SER' 'FS <br />�-, ENYIRONI4IENTAL HEALTH DIVISION — <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />YkiW+kYiii#*kkii##i##kik#AW+k+F###rtWWKWWWWKk}k*#i#*#i#kYYv%9YYYYYikWYYYWWW WWi###iiiiiis#YiYYYYWY#FiYWMW##kxiY <br />SECTION 1 - Public Health Services Envirortmental Health Division Tank Tracking Sheet shall accompany eacb tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services P.trvironmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITYNAME: �AsT-GA��-1SII`�SK <br />FACILITY ADDRESS: -?5-7 FAST iia` a -T 70N C n CR <br />TANK ID #39 QD-53q b TANK SIZE: ".'V1 PREVIOUS TANK CONTENTS: <br />ki VSRiiARII VWV VWiii YV WYV IINRWWWIIkiiV Yi R iYIIYII¢VYY# <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address _1_2,n c CC II T41 City:M STU ,_ zip: <br />Phone 4: ( Date TaW/Rcmoved: 3 —oC <br />WAWiiiII#+eiIIIIW YYYYWWYt#### <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: 4aC uT Nt�Yc�/9C�mF� +iD Yi{� L t trut <br />Address: ` ' CA W <br />'sx. �} LQ' . City:_)VE%6Xl�t1i�Zip: <br />Phone a. ( 2114� ) 5-.;`1- C� 653 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />maturer as required by Cal EPA. _ 1 <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/ pt g. <br />Facility Name: ra` E�ry C"3 <br />Address:j (% � t Zip: <br />Phone <br />11 <br />EH 23 046 (Revised 08113199) Page 10 <br />