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C <br />�... , n*ZMFIT(*- :* le IKSI <br />... <br />.ss.�s�.ssss��#ass.s,ss.sssaaaaaaaaaaaaaaassaaaa�s;s.sss�ssssssssss.sss�.s�s===arra»aaa==aaa=.aaaa,aaaaaaaa <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 />FACILITYNAME: Bldg. 647 - DDRW - Sharpe Depot <br />FACILITY ADDRESS: Roth Rd., Lathrop <br />01""Mtr <br />Tank Description: <br />ssssss:s:ssssssssssssssssssssssss:asssssasssssassess:sss�ss�ss�ss:ssssssssssssesssssss:sssssssssssssssassss <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor: Q i l F n i i i o m P n fi I; P r V 1 f` P <br />Address: P . 0 . Box 950 City: San Andreas Zip: 95249 <br />Phone :{ 20 9a 754-1808 Date Tank Removed: <br />SECMON 3 - To be filled out by contractor 'decontaminating tanr: <br />,k Decontaminati n Contractor Oil EquipmentService <br />Address: P .0 . Box 950 City; San Andreas ZIp: 95249 <br />Phone #: ( 209) 754-1808 <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: 71tie: President <br />Keith A. Tallia <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:Triangle Inc. of Sacramento <br />3525 52nd. Ave. <br />Address: P.O. Box 9795 City; Sacramento Zip: 95823 <br />Phone #:(916 421-1990 <br />Date Tank Received: <br />Signature: Titles <br />ssssssasssssssssssssssasssasasssssaaasses:ssasassass:s��sssssssssssssssssssaaaassaassssaasassasasaaaassa <br />EN 23 049 (Revised 7-10-92) Page 10 <br />:r <br />