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:sass:sssssssss«sssss:««s«ss•s:s::ss:s::sass:.ass:sssss:•sssass:sssss.ssss•s•sasses:ss.sssssssss:••:sss.s«s <br />SECTION 1- Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br />The Tr2cldng Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br />reqmllng ftillty. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACMrrY NAME ANASTASIO'S AM/PM MINI MART <br />FACUJff ADDRESS:— 3425 Tracy Blvd, Tracy, CA <br />TANK M #39 - P( Tank Description: <br />..sssss«s«s:ssssssssssssssssssssssssssssss::sssss:.sass«ss•ssssss::ass:ass«ssssssss:«:sssss:sass«sass:ss«:s <br />SE ON 2 - To be filled out by tank removal contractors <br />Tank Removal Contractor. <br />Address: City. Zip: <br />ff1hone #: Date Tank Removed- <br />SECMON <br />be filled out by contractor "decontaminating M <br />Tank c. n cs .r Contractor. <br />Phone <br />. ► ► t e► manner r .r er by <br />Signature: Title.. <br />sssssssssssssssssssssssssssssssssssss:sssss::sssss:ssssssssssssssssssssssssssssssssssss«sssssssssssssssss:s <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 />Address: City; Zip: <br />Phone : <br />Date Tank Received: <br />Signature: Title: <br />«s«s:ss:«sssss«««,«ass:s::s«s:s:::ss:s::ss::.s.::::::s:ss:::«s:«sass:s«ss«:«««««««:«««:«:s::ss«:::•s««•s <br />EN 23 049 (Revised 7-10-92) Pape 10, <br />