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Nor <br />r. <br />UNDERGROUND STORAGE TAMC DISPOSITION TRACKING RECORD <br />..........................................i.............,....,...,..,..,,..,..,............,...........,.. <br />-he TION i -Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number, <br />3e ling fang Sheet a pe m returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br />�c�g facility. The permit holder is responsible for eastiring that this form is completed and returned. <br />7ACULr1 Y NAME: (4-o 14 _ c --Z- G i i <br />ACILITY <br />A -VK ID #39 - _ Tank <br />N <br />- sfeel- 0/1e-- <br />.................. a ..... ,............... I ..................... <br />............................................ <br />ECTION 2 - To be filled out by tank removal contractor: <br />9rk Removal Contractor._zYL ?' <br />Citv: sacra �?�O ZP ys-gZz <br />one ( �J/ �) ¢ZZ - Z6 C � Date Tank Removed: <br />................................................... I................ <br />:CnoN 3 - i ....................................... <br />o be filled out by contactor 'decontaminating tank% <br />:rk De; ontaminatioa Contramnr JZ,., /_ - -/- / -- <br />City:Sal�q , u�{, Zip: 575-f-? Z <br />tone (q//� )�CZZ -Z6 z_ S- <br />Proved <br />mannrepreer <br />as required <br />of contractor certify ng through signature below that the tank has been decontaminated in an <br />proved manner zs required by Cal EPA. <br />.........................................................................--- <br />'MON 4 - To be signed and dated b 0........ <br />accepting tank and/or piping. trea.................... <br />y authorized representative of the tment, storage, or disposal facility <br />Airy Name: <br />one #: <br />to Tank Received: <br />nature: <br />City: Zip: <br />Title: <br />......................................................................................... <br />............ <br />3 O49 (Revised 7-10-92) <br />page 10 <br />