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CJ • • • a t' • ray a r • XX%XXXX%.XXX%%X.W%W%XXX..%%X%%*XX%%X%X-XXX-W...%.XXXX%Xx%XX%%X-XXX%X%�=XX%X%%XXXX------X- %%%%XXX--- SECTION I - Rublic Health Services Environmental Health Division Tank Tracking Sheet shail accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be resumed to Pubiic Health Services Environmental Health Division within 30 days or acceptance of the tank by the disaosai or recvciing ;acuity. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: ^ACILiTY ADDRESS: -ikNIK ID -39 - TANK SIZE: j 00 p —PREVIOUS TA -NK CONTENTS: -XXX%X%%XXX—--- %XXXXXX,LXX--XXXX%%% ------------------- %%X%X%x%XXXX%%%X%%%%X%%X-----%%%XX%-----%X%%%%----- SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Address: City.: Phone = : ( ) Date Tank Remove:: 93 XX--------------------- XXXXX%%%-X-XX%XXX%%X%%XXX%--X%%X%-X%XXXX-XXX--X-XXX----%XXX-X%XX%X-----XX--XXX----%% SECTION 3 - To be tilled out by contractor "decontaminatincr tank": Tank Decontamination Cont-Lac.or: J V .-'address: 4 � 0 , �/1 City: v Z:D: 952 O .� (�0 6, 3 3 7 Authorzed representative or contractor certify ng through signature below that the .a,,� has been decontaminate; ;n 3h approved :Canner. as .equired by Cal EPA. Name: %44 IR R2 �e S:7—e jZ Title: Aj J, _ _Si -azure: Date 9� _ -----ACX--%- XXX--X-XXXxXXXX%ACXyeA:-X%XXXaeXXXXXX-XX-XXXX%XXXXXXX%.%%-------- ---------- SECTION 4 - To be signed and dated by an authorized representative of the treatment. storage. or disposal facility accepting tank and/or piping. =aciliry Name: Address: Phone "7: ( ) Date Tank Received: Name: Title: City: Siznamre: Zro: Date XX-x%%X-XXXX-XX-XXXz-%XXXXXXXXX XXXXXXXaCXCsXXXXX�kXX-X-%XXXX-xXXX%XXXX-CkX-X-XXXXXXZXXXzz XXaK�IcXzzy�t A•;s�K�kzzz;t>Oszz EH 23 046 (Revised 9/11/96) Page 10