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SAN VICES <br />,.... , t COUNTY PUBLIC it + ' <br />ENVIROMIENTAL Hi, 1 •' <br />SECTION 1- Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />withinthin 3Q days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: wet' SccC.1'a M @ n <br />TANK ID 1139 - TANK SIZE:jt)oQ 61PREVIOUSTANK CONTENTS: ,Qeg <br />SECTION 2 - To be filled out by tank, removal contractor: <br />Tank Removal Contractor:_ Werdk <br />6 k • <br />Phone #: 2Qq) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />City: <br />Zip: <br />Phone #: (� <br />authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Tide:— Signature: Date <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: C17 `` <br />Address: `. � PACC -[;\\)A City: QOGh MOA Zip: g ga <br />Phone #:, (,-„�L) 235-M'13 <br />Date Tank Received: <br />Name: Title: <br />S' e• Date <br />EH 23 046 (Revised 10/19/98) Page 10 <br />