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} <br /> UNDERGROUND STORAGE TANX DLSPOSITION TRACE2NG RECORD <br /> ......a......................a.....aaaa.........aaaaa..a..aasao.a..a....aaaaaaa.aaaaaauaaatafasaa......... <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 /> FACILrrY NA.�: �Ba(fil�� tiTP�c- C aL�✓f' ggD-� <br /> FAC1L=ADDRESS: �M�t t�j �rU i�{Q— �09-/ • D R/ / u <br /> TANK ID :39 - �Z.J Tank Descripdon: qi U11�� 6,4b - 1�1A <br /> SECTION 2 - To be filled out by nk removal contractor. <br /> Tank Removal Contractor: �?�/1/t(' <br /> Address: 17/17 S - /7r* 'Z City. f Zip: <br /> Phone ( �� ) S 1 ' �6 3 Date Tank Removed: 7-/ -11!� <br /> •.a........................................................................................................ <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank": <br /> Tani• Deconta=adon Contractor: <br /> Addr ss: l7/I ? is `7� City. � `I�CO zip: �S3 S'I <br /> Phone : ( ��) Su/✓q65 <br /> Authorized represe tative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approve m equ',ed by_Cal FPA <br /> Signature: Title: <br /> ..............................................................................I............................ <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:( �01���fiQ 'Jito c (0 <br /> Address: I`I o City. ((J(c��f r7fi Zip: <br /> Phone <br /> Dace Tank R 'v <br /> >ignatu (AJ Title• <br /> ........................ .......................................a...................................... <br /> Eli 23 049 (Revised 7-10-92) Page 10 <br />