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SAN •. •1CO4B,-_rT__P#BLIC HEALTH <br />ENVIRONMENTAL HEALTHDIVISION <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: Q c1G et a9 <br />FACILITY ADDRESS: j 2 7Z S LX2 LGr_ Is t=y & 0 <br />TANK ID #39 - j®6Z%(, TANK SIZE: /z ��,g� PREVIOUS TANK CONTENTS: C <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: % i �J i �l-`y��i C g,i <br />Address: % e EE E(? /_ L Z d 5.2 !6 City:me Zip: <br />Phone #: ( y/ 6 ) A- -, - Z, i Z 4 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: t_)_61)ZO j -,c—, <br />Address: 30 &2 City: Zip: 5 Z. 4 0 <br />Phone #: (7) L Z 4 S <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: Title: <br />Signature: <br />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: .� t-/µ.�-i'4ZE(L E t L_ <br />Address: <br />_j c1,vYi (-uc-'54.&y 6c.v'City: yf '.046-�42=4ip: 5�57�t 7 <br />Phone #: ( e16 ) %!x S - `} K 1 a <br />Date Tank Received: <br />Name: Title: <br />Signature: <br />EH 23 046 (Revised 7/10/96) Page 10 <br />Date <br />