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UNDE OUND TANK DISPOSITION TRACK RECORD <br /> »»#»»«»«»#» «««««»«#»«.«..e«»»«s.««...«.s»........ <br /> SECTION I -Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The <br /> Tracking Sheet is to be returned to Public Health Services wit in 30 dans of acceptance of the tank by the disposal or recycling <br /> facility. The permit holder is responsible for ensuring that this foris coatpieted and rewmed. <br /> FACILITY NAME: Lawrepa Live *?..e'..n..l[•Itx)rl[I)ry <br /> FACILITY ADDRESS: C'oxr H��ll��w R�u�d (v►�thwea��f Trirvl <br /> TANK ID#39- M Tank Description: W-MY g•�tNo�chi►y,�lDgle-WW!rs1_carbon-creel lank <br /> SECTION 2-To be filled out by tank removal contractor: P z7, —i u,, <br /> Tank Removal Contractor: <br /> Address: 32S m—MMAGAL 57 _ City:SA10loS1 State: C.14 Zip:9S1 I a: <br /> Phone #: (40% )4S3—All Date Tank Removed: --I 11 ) 9 y t — <br /> s.ss::»s«#«»»»««.«»ss«»rasa»#s««sssrts»s.«rte»s»sass»sssssss«««:sass:ss««ass.s«ss«�ss�sss«.s«ss«ss«�ss�ssss� <br /> SECTION 3-To be filled out by contractor"decontaminating tank": ' <br /> Tank Decontamination Contractor: N p <br /> Address: City: State: Zip: <br /> Phone #: <br /> Authorized representative of contractor certifying through sit-nature below that the tank has been decontaminated in as approved <br /> manner as required by CaUEPA. <br /> Signa Title: <br /> SECTION 4-To be signed and dated by an authorized representative of the treatraent.storage,or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone #: <br /> Date Tank Received: <br /> Signature: Title: <br /> EH 23 039(Revised 7/10/92) <br /> 10 t <br />