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• 1' • It :1 <br />so <br />LIJIM)M811MU1611M 11MIMMO 1810MV!11 •'!; <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />F 4 <br />FACILITY ADDRESS: 19 5 <br />TANK ID #39 - TANK SIZE: !! 000 PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: City: Zip: <br />Phone #: ( ) Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: f <br />Address: 3 .R . A , City: Zip:,C <br />Phone #: ( 0 )-r%D' "' % 33 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: /l _z I ` /� Title: Signature: Date qL14119 <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 />Phone #: ( ) <br />Date Tank Received: <br />Name: Title: <br />City: Zip: <br />Signature: <br />EH 23 046 (Revised 9/11/96) Page 10 <br />Date <br />