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283 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> «»s«»ssss»ss.s.s«ss.s«..s.....s..s......s........ss..s...«.»«.....s..s..s.......s.....s...........s....... <br /> SECTION 1-Public Health Services Tracking Shat will accompany each tank affixed with its site identification number. The <br /> hen iA derv:of acceptance of the tank by the disposal a recycling <br /> Tracking Sheet is to be returned to Public Health Services$iL�� <br /> facility. The permit bolder is responsible for ensuring that this form is completed and returned. <br /> FAMTTY NAME: j�W"111111111 T e.n.,,,ere National iabot2ttlrv.Sitz 300 <br /> FACII.TIY ADDRESS: �Q1-Hollow Roacv California <br /> S ,L <br /> ANK M#39 -�af t4 Tank Descriptiom Mgallffl ity ngle•walled.carbon-moi tank <br /> «s»ass«s»»ss««ss«sass«:sss«ass««««s»:sass«ss:ss«s»««sss«asses«»«:»«:»«:«»ss»s««»«.s»s.ss«»«sass»«�ssssss«s <br /> SECTION 2-To be filled out by tank removal contractor:1P <br /> Tank Removal Contractor. <br /> Address: S'Q City:�A u Com,�. State: G4 zip: <br /> Phone #: f`i®$ LA 51---L � o Date Tank Removed _ i q q -+ <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor. <br /> City: State: Zip: <br /> Phone #: f <br /> Authorized representative of contractor certifying through signature below that the tank has been decontammated in an approved <br /> 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: <br /> Address: City' Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Signature: Title' <br /> sss«sss.sssss.ssssssssssss«sss:ass:::ssssass«s»:ss««s«ss«sss.:«ssss:s««s»ss»ss:««««sass«»s:�sss.s.sssss«s• <br /> EH 23 049(Revised 7/10/"92) <br /> 10 <br />