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SAN VAQUIN COUNTY PUBLIC HEALTH SEACES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*********************************************************************************************************** <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: �A til PAS c-. VA ^S 4 <br />FACILITY ADDRESS: cgrt 1---"k-4 , GA C}520�}-- <br />-TANK--ID-#39 = p� F' 1NG-i 9P*?4* SIZE: 2 PREVIOUS TANK CONTENTS: V is lGl..i F� ELS. <br />*********************************************************************************************************** <br />Ptd' IKh <br />SECTION 2 - To be filled out by4enk removal contractor: <br />Tank Removal Contractor: 11 1 r1 � Cm t A = . <br />Address: P-0. `3-0X ( x-03 <br />Pt <br />Phone #: O S IJ:5 1 O Date T-ank Removed: <br />City: L.U()1 ! Glut Zip: 1 <br />*********************************************************************************************************** <br />SECTION 3 - To be filled out by contractor "decontaminating kswkd',: P i P e <br />Tank Decontamination Contractor: W C-- I-4 U k �01`�L`i". <br />Address: P. O • aO)C 14<73 City: x-00 l , G4 Zip: q <br />Phone #: <br />Authorized representative of contractor certifying through signature below that the4ank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />IN."M <br />Title: <br />Signature: <br />Date <br />*********************************************************************************************************** <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: <br />Phone #: ( ) <br />Date Tank Received: <br />Name: <br />Title: <br />City: <br />Signature: <br />Zip: <br />Date <br />********************************************************************************************************* <br />EH 23 046 (Revised 08/13/99) Page 10 <br />