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11 <br />1a' 1) P30 t r - � 1 <br />«•ss«sss«s•sss:«ss:•sss.ss•«sss«s«s«s«ssssssss«s•ss•ss«:•sssss«sssss••«ssss••sss•••sss••ss«::::•ssss««••:ss <br />SECTION 1 - Public Health Services Tracking 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 ftc1lity. The permit holder is responsible for ensuring that this form is completed and returned <br />FACILITY N ANASTASIO ° S AM/PM MINI MART <br />FACE= ADDRESS: 3425 Tracy Blvd, Tracy, CA <br />TANK ID #39 - — Tank Description: <br />sssssssssssssss:s:ssssssssssssssssssssss::sss«:sssss:sssss««ss«s««::sssss::::sssss«::::•:•ssss•:««sssss:::s <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. <br />City: Zip: <br />Phone #:( Date Tank Removed: <br />«s•«s•ss••s.•«•••••••••s•••••:•«.««ssss.:«:«s««s«s«.««.••ss«sssss««:::.sssss«sssss«•:sssss:«•«.sss«:ss««««« <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. <br />Address: City: Zip: <br />Phone <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 />= <br />Title: <br />ss:s:sssss:s:sss:::sssss:«:s:s:::s:s:ss:ss::sssss:ssssssss:sssss::s:ss:ss:ss«s•••:::ss•sss««ssss:s:s:ss««:: <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 />Phone #:( <br />Date Tank Received: <br />Signature: Title: <br />«ssss«s:ss:ss•••ss•••:ssss•s:•s:s:••«:«ss:•«:::«ss«s•:ss:«:::ssss:ssss:«s:sssss««ssss«•«sssss«ss«::ssss• <br />EH 23 049 (Revised 7-10-92) Page 10' <br />