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RIZI i � IF I <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br />The Tracldng,Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal oll <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACIL= NAME: <br />FACIL= ADDRESS: Z <br />TANK ID #39 - I Tank Description: <br />SECTION 2 - To be filled out by tank removal ctor: <br />Tank Removal Contractor: <br />ME <br />Phone #: Date Tank Removed: <br />SECTION 3 - To be filled out bycontractor "decontaminating tank": <br />Tank Decontamination Contractor:ar <br />Address:Zip: <br />------ Q kc City:® <br />Phone #: <br />Authorized representative of contractor certffying through signature below that the tank has been decontaminated in an <br />approved manner as required by Cal EPA. <br />Signature: Title: -- <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal faciWm- <br />accepting tank and/or piping. I <br />MEMCMINWO <br />Address: <br />Phone #: L-? LLej 14 q <br />Date Tank Received: <br />Signature: Title: <br />EN 23 049 (Revised 7-10-92) Page 11 <br />