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UNDERG LTND TANK DISPOSITION TRACKING RECORD <br /> ................................ ...................................... .......................... <br /> SECTION I -Public Health Services Trac ' g Sheet will amompany each tank atfrxed with itt identification number. The <br /> Tracking Shat is to be returned w Public Health Services wirhie'4t d-'vs of acceptance of the tank by the disposal or recycling <br /> facility. The permit bolder is msponsibk for ensuring that this form is catnpkte0 and rettrmod. `, <br /> FACII.I'IY NAME: y..,:zrre Livermat Naconal L�Marranb 11�Y <br /> FACILITY ADDRESS: r •*'-"-w Road T Cali ania <br /> �jr Tank Description: le t carbQn•saeel tank <br /> 11 , <br /> SECTION 2-To be filled out by tank removal <br /> Tank Removal Contractor. <br /> 52S Comnnla4c L,5r _ City: ate_ State: CA Zip: Ck)f <br /> Phone •: L 4 O1 ) 4S3—)M Date Tank Removed: <br /> SECTION 3-To be filled out by eonVactor' taminadng tank': <br /> Tank Det:oatamination <br /> City: State. Zip: <br /> Phone a: �. 1 <br /> Audonzed fepM==ve ofco==cerdfying arwo signaLwe below that the tank has been decontammated in an qpwed <br /> amum as mquU-ed by CaVEPA. <br /> Signature: Tide: <br /> 0wseWM**0w* 000000"0000 <br /> SECTION 4-To be signed vid dated by an authorized representative of the Munat.smgc.Or disposal facility <br /> IMCCC;King piping. <br /> Facility Name: <br /> City: Zip: <br /> Phone 9: ( 1 <br /> Date Tank Received:- <br /> Signature: <br /> eceived:Signatu e: Title: <br /> EH 23 049(Revised 9/10)92) <br /> 10 <br />