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site <br />SEMON Public HealthServicesTrackingSheet will acoompamy each 1affixedwith Itsidentification 1 fr 1.-.. <br />'Me Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br />recycling fhcillty� 'Me permit holder is responsible for ensuring that this (om is completed and returned. <br />- <br />1. <br />FACHATY ADDRESS-CrO <br />• <br />TANK ID #39 - Tank 1, t a r <br />------------- <br />SECTION 2 - To be filled out by tank removal contractor: <br />a= <br />Phone#:( a 07 Date Tank Removed: <br />SEMONbe wf oUt by contractor"decootaininatingtanV. <br />Address: .i., b: <br />Phone r <br />approved manner c: f by Cal EPA. <br />Signature: Title: <br />GECTTON 4 - To be signed and dated by an authorized representative of the treatment, storaM or disposal facility <br />accepting tankand/orpiping. <br />Name.Facility <br />s <br />Address: r <br />is <br />Date Tank <br />Signature: Title: <br />EM 23 044 (Revised 7-10-925 Page 10 <br />9,d 90 L 0LLZ6OZ 8V1S1S3M/dV1S11V WOdA "V L L = 6 966 L —6Z—V <br />