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ass.sfe...•e...esa...sees sees so*** e..ees.tesee .ts..s....eteee.e t...e....eee.ee.e.ee..... <br />SEC- ON 1 - Public Health secviom 'racking Shit wit laompany each tank affixed with ire site identification nualbei. <br />'lye Tracking Sheet is to be rcUnnitd to Public Health StrA= MftWffjL4M of acceptance of the tank by the dbVOW or <br />recycling facility. The is responsible for CnSWbg that this ft= is cosapleted and returned. <br />FACnZrY NAME: <br />FACII.]'T7C ADDRESS: I LPI `l MEPA <br />TANK m #39 - 14611 - 0 :2 Tann Description: <br />SECTION 2 - To be Wed out by tank removal contractor. <br />Tank Removal Contractor, Irk ST ; At? tja Q.p,., M &ZAt,- <br />Address: 44x1 S lut �` E4 E <br />Phone #: "937 <br />0 - Date Tank <br />...ea,e......t...................e....sla.s...e....... s........ mm.1......a4.e...e.. a.....eee.a..t.t.a..ee* <br />SECTION 3 - To be Wed out by contractor 'decors ' g tank': <br />Tank Dewntangnation Contractor- (,cfl=--;r;� 'AA - ENy t L,0 J MexJrA[II tl L - <br />Address: 7-1p: <br />Phone #:;:77 ;:77 ly7S - <br />Authorized representative of contractor certifying through signature below that the tank has bees decontaminated in an <br />approved manner as required by Cal EPA <br />Signature: TKI <br />sass.:assess.. s.s...a........s:s.ses.sa.e..ssae...s..ismmmmssmmsss.sass.ssssets..s.ssasss.ess..stss.sssesas+ <br />SECTION 4 - To be signed and dated by an of the treatzoant, storage, or disposal kacfflty <br />ting tank sudor piping <br />Facility Nath <br />Gity: JgZa5evU Zip: <9374Y—S:2-.2 <br />Phone #: <br />Date Tank R <br />Signature: Tiie: <br />.ass+ss..a.asses,.ssssssess..seas.ss:ss.acts.sssmmssss..asses.lasstsessssstts.s++ee+.s.s.asa..asessas. <br />ES 23 049 tRavised 7-10-923 P"e 10 <br />