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JUN -20-96 THU 10:45 AM SCOTT 19163666908 P.02 <br />,roi 6 <br />{ <br />saAsasasss*assssssssssses*a»+wsarwA+leas«srm$$s$awasw.w$*+#asia+Aaaa+Ras$s$a$as$$s$sasvaaws»a$assaassra$sxxs$xaa <br />SECTION 1. - Public Health SeMctes Tracldng 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 />FACILI'T'Y NAME: : LO " e L t o o vvz k [— vo r7 S Tc, ve- t <br />TANK M Description: <br />eesaseasesasasaa�asssssaxsssasssa•arsaaasesasssasss*r**ease*$ease*aessa�R,Rwsasaewswsassa�Rsasassaaae$e#s$ssaa$ <br />SECTION 2 - To be filled out btank removal uractor: <br />Tank Removal Contractor: Lj� rM eS,r�? <br />Address:_ !q & Ri C4 f1 Car.zip..— <br />-1 S <br />Phone #: ( S.&F — Z tom. Date Tank Removed: <br />eat***Mars*swsAs$saixaw aesessss*exa$a e****ase*sass*axe*ssaa as as asaaaaassatesaaxY+ARdlµ+►a:ease ea* a w M as. a**$s$a$ <br />SE ON 3 - To be filled out by contractor *decontaminating tank': <br />Tani: Decontamination Contracto <br />Address: 7 f 0fit 'Z' t City:. Zip: Va Z Z <br />Phone #: ) 4Z Z 2 — 7.G -v- -� <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: Mile. <br />ease$asasaakwsaxssissa*ssasaaaicsssswx�MassxsxsaasMssssssa#aaa*axe*atsasa#aaaaasa*sses�RsaaaAxa*sssassA#sxasass <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank andlor piping. <br />Facility Name: I { sa' N i; ►,a v t Rra n� r4t� to �- wE t <br />Address: [��,c1�? +5i5! CityyQs�vt , , Zip: _ jMrs <br />Phone <br />Date Tank Reecivcd: <br />Signature: 'Iktic, <br />s#seas+asa4*s*eesaa*�esaxasaaaaaxssasaes■aassaasasAsasasass**sasses*Mea*ssssesa�rrRMss�x�sss**ra+uax�sesssses <br />Etc 23 049 (Revised 7-10.92) Page 10 <br />