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sss:ssssssssssssssssssssssssssssssssssssss:sssssssssssssss:ssssssssssssssssssssssssssssssssssssssss:s:s: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 daps of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned <br />FACILITY), rN•. 1 ��r <br />1 r•IN• <br />Tank Description: <br />:sssssssss:s:s:ssssssssssss::::sssssssss:sss:::s::s:::sssssssssssssssssssss:sssssssss:sssssss::::ssss:ssss: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. t5 i , J t l <br />Address: (aJ . 1 ( City. RJEW <br />• _ Date TankRemoved: <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 />Signature: Title: <br />ssssssssss::sssssssssssssssssssssssssss::ssss:ss::sssssss::ss:s::::sssssssss:sssssssss:sssssssssssssssss: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 />Address: <br />City: Zip: <br />Phone #: <br />Date Tank Received: <br />Signature: Title: <br />:sssssssss::ssssssssssss:s:ssssssssssssss:ssssssssssssss.s.ssssssssssssssss::ssss:::::::$::ssss:ss::ssss <br />EH 23 049 (Revised 7-10-92) Page 10 <br />