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««s«ssss.ss«««s««ss«sass«««««s«««,«,,s««««,s««,«««ss,s,«,s„s««s,«s«« „«««««««««•s«ss««•s««:«,s«•«s«s«ss•«s <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:_ _ T A C e �l C � e 11 �u �-O q;1 --( # 2 - <br />FACILITY ADDRESS: 3�tS r f ou Uin J&r(rt � tock lob <br />TANK ID #39 - Tank Description: e��j��/ �q� �U/\ -"t, <br />•ss,«««s««««ss««««ss•sss«s«s«s««s««s«««,«ss«««,«.-ffi,«,,,««««ss««««ss,«««««ss««««««ss«««s««««««s««s«««s«s««s <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: A rn n �x, E n i d n,-&,1 t <br />p / 6ACr <br />< vAddress: � l J lC r J�f� City:L—CfdPNCAL _ Zip:_ <br />Phone #: Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "d tank": <br />Tank Decontamination Contractor: ��td�e Itaminating <br />En-)c 4nmeA, 1 &ry([e S <br />Address: � 1315 "sl- DrLuc City: J�(Ln6rNJ Zip: Yq �� 6 <br />Phone #:( (a )_ 222—'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 <br />Address v��� w- r RI UJ City <br />Phone #: <br />Date Tank Received: <br />Signature: Title: <br />s•s«««««««ss«s««ss«ssssss•sss:«•ss«as«asses«sss«sssssssssssssssssssss««««sass«ss«•ss«ass«ss««sssss«eases <br />EH 23 049 (Revised 7-10-92) Page 10 <br />