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0 <br /> UNDERGROUND STORAGE TANK DISPOSPPION TRACKING RECORD <br /> SECTION 1 - Public Health Services Tracking She <br /> c Health Services within 30 days of acceptance of the tank by the et will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to Public <br /> recycling facility. The permlt holder is responsible for ensuring that this form is completed and returned. disposal or <br /> FACILITY NAME: X <br /> Ijn <br /> FACILITY ADDRESS: �>'7a� «� ✓� �Ah�� 9,533(0 <br /> TANK ID #39 - Tank Description: g011Of� <br /> s,•••••ir••q•p•••••p••,H,••••••••sr•,•••••,•s.,•a•♦••.•••.a•b,•••w••,•••••,N••,,,,•q•••t,H•ti•••• <br /> SECTION 2 - To be filled out b tank removal contractor; <br /> Tank Removal Contractor. — nq 10 Zhu <br /> Address;�9 b( 46n �. J <br /> ^, city:_ Repan zip: G5540b <br /> Phone #: Lk---I ) g _ <br /> Date Tank Removed: <br /> SECI-ION 3 - To be filled out by contra or "decontaminating tank': <br /> Tank Decontamination Contractor.��Vdlf� �rn1;4 &)J—Iy <br /> Address;_ " f, i <br /> City: Eipl _ zip: gUu(a <br /> Phone #: iLgaj n—_047 <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: nlGZt / � C <br /> Title: <br /> ..•••••,••••••rp••••••••••••••»••s••s••••••,•,•,•••••••••••••..••••••••••••••,••••,••••.•••••••••••••t•••• <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.---L)- CQ0,<L <br /> Address: <br /> city: 7,vincr zip: 9h 38U <br /> Phone #: <br /> Date Tank Received: /3— <br /> Signature: 1— <br /> Title: <br /> EN 23 049 (Revised 7-10-92) <br /> Pepe 10 <br />