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ieasxxY*�exiceiezxxas aKzzxxxaiexxatxzxfleXezz:zxx*xxxzxzzaexxxx�e]leflexxxxxiexxxxxxxxxxxxxakxxxzxxxxaRxxxxxxxxaeIexxxxeac>OcxzXxxxicXxzx <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 />FACILITY NAME: <br />FACILITY ADDRESS: 9 8 <br />TANK ID 11#39 - <br />TANK SIZE: 14 D®O PREVIOUS TA!INK CONT'.:,_NTS:11,,,, <br />xXxxeie ]Kxid... W.....xxxxx s --- *Xx ----------- W ................. ...... XXXXxXXXXX XXxxX]eX -------------- <br />SECTION <br />xXXxa[XxXXXX3RXSECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Phone r: ( ) <br />Date Tank Removed: <br />City: <br />Zig: <br />xaexxsx Mge>lezme les xxxx Xxxa[sxxxxx s.kxaiexzX xxiefexssaksak z;eye%ezmexx XXXxxxx�eapcxaie m:mea�esiezxi#s.cxxxx Xx:xseaie zem?e xak�ak�zxxx xz�k �sxxaa:xs:xxx <br />SECTION 3 - To be ailed out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: a, 1 V <br />Address: S W %,1A , Cirv: Zip: 7 S Z o S <br />Phone n: (', Q % 3.3 % <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: /� ,q T2 sx �E S T 12 Title: PAA, Signature: Date/ 9 <br />etae elaalcxc�!e aloe ele�eere �kzsAe �cxxsheyex�eeiexaeajeXe akmaexx�K�xaea�eseieaaakxeiepex�kXazeF�kaezxaeiealeXeseaiex�de�x�Pexxar�ezxx�exzx�eAerteleac�Ieaexesek�k�kaaxxae���M x777*"' �exaa aexx�k�Fzxs <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 />ale �F �e:xx%1{zaK yFA`ezre sie akxx Xsak%:kxskeaka�e ekzeleela ye�de <br />EH 23 046 (Revised 9/11/96) <br />City: <br />Signature: <br />Zip: <br />Date <br />