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9 0 <br /> 000088 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> r♦aaw..sw...........s.rrwrel........aaaBaaaiaaawaaasaaaf awwwsi#####wa+aisaaa####sssaaaasaa4aasas*wwaw.ra.a1 <br /> SE(T10.,� i . ins^; I lealth Services Tricking Sheet will accompany each tank affixed will)its Site identification number. The .. <br /> Tracking Sheet t%fo txs returned to Public health Services within 30 days of acceptance of the tank by the disposal or recycling <br /> facility. The prrmit holder is respentsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: Lawrence I.iveanom National I.abomitoty,Site 3(X1 <br /> FACILITY ADDRESS: ('octal I Iollow Reead.(southwest of'I'rtcy).('alit miia <br /> TANK IU#39- ank Description: 3(X)-lallem capacity.sin+le-walled,carton-steel tank <br /> SECTION 2-To be tilled out by Link removal contractor: <br /> Tank Removal Contractor. ?1:—, P'o j +..Y <br /> Address: GQJ t*rn YI F_/ULAL 5`� City:!S&N ZT135k. State: CA Zip: 9S,19, <br /> Phone #: (k_p) t-IS Vii' � Date"Tank Removed: <br /> SECTION 3-To be filled out by contractor"decontauninating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: State: Zip: <br /> Phone #: ( ) <br /> Authorized representative of contractor certifying through si_naturc below that the tank has been decontaminated in an approved <br /> manner ae required by(-d/EPA. <br /> . 1 <br /> Signature: 'Title: <br /> SECTION 4-To he 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 #: ( 1 <br /> Date Tank Received. <br /> Signature: Title: <br /> -EH 23 049(Revised 7/10/92) <br /> 10 <br />