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ssssst**«***«s*««««««ss«stt*:ssssst:«sstst*st��sssssset*sstssttt«ts**ss*s*ssss*a«s«sett*setts**ss«**ss«s«st <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 days 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 NAME: rack- is Eel < <u� o�+�� T«�c 0.T <br />FACILITY ADDRESS: 3ItS N -\,o4 4 �ouNvtn ��rCrl i avn <br />TANK ID #39 - Tank Description: ;�-. 1000 --aaI lon S <br />ss««ssssssssssssssssss«s«t««*s«*teras*:ssss*«tess�.stt«:ssss::::::««tts*ttsssssts:sssssssssssssss«sss«t«sss <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: A rn n e n I n c <br />Q ../ _j_ �NJ j/ <br />Address: S� t ) cLnLer S t f��� City: ( f CAL _ Zip: �0':�k8 <br />/ a <br />Phone #: (� i� ) 39/—/ b D 0 Date Tank Removed: <br />tttttttt«tssss:«essss«ss*ttst::tttetttte«tt:«ett:tt.t.sts«tett:st::nests««etttttset..tt«s«ees.ss«tt«.setts <br />SECTION 3 - To be filled out by contractor "dQpo taminating tank": <br />Tank Decontamination Contractor: <br />Address•`3 g Lake& (� P DrLU* <br />P City: ZiP:- B b� 6 <br />Phone #:(9710 )_ 2,a2-7910 <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 />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: SO <br />Address.• parr 1S� V City: Zip: <br />Phone #: <br />Date Tank Received: <br />Signature: Title: <br />EH 23 049 (Revised 7-10-92) Page 10 <br />