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n <br />0a" -�lr�, I) MOIR V V ll� =ID <br />s:s::ssssss•«ass•s•ss•s.«ssssssssss,sssssr«•:sss:sss«•s••«ss:s:s«:sss«•.s:••««s•s•«s•«•sss«ss:ss••s•sss«ss« <br />SE ON 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 facility. The permit holder is responsible for ensdring that this form is completed and returned. <br />FACU= N ANASTASIO'S AM/PM MINI MART <br />FAC D 3425 Tracy Blvd, Tracy, CA <br />TANK M #39 - I L .r~' b � Tank Description: <br />ssssssss:•:ss••sss.:•:ss«:•s•rssssssssssss:sssss:::rr:«:ssssss::ssssss::sasssass::s:ssssss,sss•:ssssssss•:s <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. <br />City: Zip:, <br />To be er out by contractor c• rtank. <br />Tank Decontamination ♦ r t <br />Address: City: <br />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 />Signature: °Hue• <br />s:ss:s:ssssss:«•ss•::sass::s::sssss«::::ssssssss:ssss:s:ss:s:::ss:s::sss«s:ssssss:sss:::sss:ss::•s:«s:s«sss <br />SECTION 4 - To be signed and dated by an authodzed representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping <br />Facility Name: <br />Address: City: <br />Zip: <br />Phone #: (_ <br />Date Tank Received: <br />Signature.• Title: <br />ss:s:s:ss«ssssssss«••sss:sssss::«:•s:.:s::•ss•ss•ss•sss::sss•::s«sr:ss«sssssr«:•ss:•ss.:sssss«ss:s«::ss: <br />EH 23 049 (Revised 7-10-92) Pape 10' <br />