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ssssssssssssssssss::::::ssss::s:ssss:::s::::::ssss:ssss::::ssss:ssssssssssssssss:s:s:ss:sssssssssssssss:sss <br />SECTION 1 - Public Health Services Tracing 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 <br />FACILITY <br />TANK M #39 - Tank <br />ssss:s:s:ss:ss:s:ss:s::ssss:::ssss::s:s:::s:::::::::ssss:::ssss:::ssss::s:ss::ssss:s:::ssss::s*sss:::::ssss <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />PhoneAddress: V,5�1 &a-&VINJ cnw-f- City--!1V&rr6-Y&Mp: q4r;K� <br />r Date Tank Removed: <br />sssssssssssssssssssss:s::sssssss:==s==s:s:sssssss:ssssssssssssssssssssssssssssssssssssssssss:ssss::::::ssss <br />Tank Decontamination Contractor. <br />Phone #: L—r2iD (:Q ?� -0� I i <br />Zip: 1 Loi <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 />::sss::::ssss:ssssssss:s::::::::ssss:::::sss.:::s:ssss:s$ss:sss::s:s:s::ssss:::::::ssss::::::ssss::::ssss:s <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 />/�►,�Ilt <br />Address:.I 1�� Iii city1WJmiW'r• <br />�1 <br />Date Tank Received: <br />Signature: <br />Title: <br />s:ssssssssssss:s:sssssssssss::sss:::::ss::sssssssssssssssssssssssssssssssssss*sssssss.ssssssssss.sssssss <br />EH 23 049 (Revised 7-10-92) Page 10 <br />