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� Now <br />L tai► �►. , a � � • . � � - � ,� � . � <br />*seaasss..mssm..meas,..a...s.a.ss....ss,s.as..,esssss......ms.ms..mea.sa.,.,.ssss.ma.aamssa.asa.aam <br />SEMON 1 - Public Health SezvicM Tr=king Sheet will accompany emb tank Affixed with its site fdentificadon number. <br />The Tracking Sheet is to be returned to Public Health SarAcm within 30 dare of acceptance of the tank by the disposal or <br />recycling facility- The Permit h0lder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: =e'A ren) M 1 N 1 M A Q. -, <br />FACILITY ADDRESS: i ern- yns ►Tt= r U<-Af-Oe <br />,........a.ewaaw.1.a.f.....a.aliGoa a.ta..ma.a.s.ms.►a..s..,...mf1.......,..am,...,,.sa.,sa,,,...ma...a. a.,. <br />SECTION 2 - To be tilled out by tank MMOV21 contractor. <br />Tanis Removal Contractor. 1&-j= 5:rAFi+:J t Q4N.3 <br />Ada 41 W T t i, A` (,0i sty: A� 710: <br />Phone : Date Tank Ranxwe&* <br />..a....a.....s..aa..a.aw.a.aw.aa.a.ta..ss.a,..feu.e.mi......f.f.m.a..a...lfasw.m... a.sisaaam.aati.aalaa. <br />SECTION 3 - To be filled out by contrMcrof admilt2ininating tanY: <br />Tank Decontamination Cont actor._ <br />Address- y6aGJ A fn,Z- <br />Phone #: ;:77 TO <br />Authorized Mteantsti" of contractor certifying through signature bam that the tank has been dectitimminated. in an <br />approved manner as required by Cal EPA - <br />Signature: Twc: <br />.• a s sts sus.l.ms..s..ms.....ssm.a..msa�s�� nota.a..nava.1.eswww.w.vasa.0m001,0000a0.a,....a..,,...wasaa a***** <br />SECTION 4 - To be signed and dated by as autherized represwtative of the treatment, storage, or disposal &Cflfty <br />accepting tank and/or piping. <br />Facility <br />Address- 3��` 5. F7'_i'? ClZip: 4!?371Z_-.3au <br />Phone #• <br />Date Tank Received: <br />Signature: Title: <br />.a,ts sw.,,,.ernsma•s,..... 000*as0s <br />EN 23 049 tRsviwsd 7-10-92! P"M 10 <br />