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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> atlt»liltltxYttlltitt}}}x»t++ttYY}++iYiitixtYititYYi+liYiY}}+YYill RfifiYY++rrttt++kYtttifiaa+rria}lir Hxittitt <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: <br /> FACILITY ADDRESS: <br /> TANK ID #39 - Tank Description: <br /> •rkxtarr+aassafififirr}ssxx+ttt+++itttsrrs+aifitri++aiirrr+a}atiafiaasaxaittat++}fittsrtas+tits It+a+fitaasasssa+aa <br /> SECTION 2 - To be filled oK by tank removal contractor: <br /> Tank Removal Contractor: tnES <br /> Address: �. ( . BDK 2 i t(j City: U��Ai� �n+ Zi IQ�jI�} <br /> rr P� <br /> Phone #: (�()� ��� ' ��7y Date Tank Removed: <br /> arrYii+t+taf ififii»rtYtt+}takix»irtti+i++++axirit}}++}+xYiiittttt+tkxitrrtta+a+fiiirttilRi+irrtltiita iai Yiiia+ <br /> M 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 /> l+laxifi+firir»tYiitittx+++x+xixixfixati YitYttt+ti++aitiYY}rrt}itattiixki»ififiit}li+fiaRxfiifilaYYittiaf itlxittti• <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 /> aaaaiart»til»irtt+•trt+++:rxria+++++sxlttti+t+Y+rrs}trrrtisxa+ixx»fitYY»sfirYtr+atlss++isxfixsx»rtii Yrtias+ <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />