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1111 ! 1 11 Ili 11 IiZl •• •� �. a �_� <br />••tttt•tYYtittYtt«t»i tR iYtttititttii»/«t•t♦tiR»itii»»itttRi»YYtRittYY t»ttt Ytttitii»t inti ti tii Ri«if Yttttt•t <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with Its site identification number. <br />The Tracking Sheet Is to be returned to Public Health Services wit in 30 dans of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: LIU,'PU-Mtn , cp4v, 0 Lock, <br />FACILITY ADD Y 55, N : C+Ver O kE C- c_.N <br />TANK ED #39 - Tank Description: <br />ar,, SECTION 2 - To be filled out b tank removal contrTank Removal Contractor. klhL'70 K4 Et lti <br />Address• <br />,;8.4-5 City: .j�2 p. r.(t PMITD 2:1p; Qi SCo�i <br />Phone #: ( q �b )-'3-11 " 1 e%ur-1 Date Tank Removed: <br />•mitt*»ttttYYtti»»«»i«»t»ett»»ttR»»vtR»»titi»v»YtiYYYitRi» tvvv <br />SECTION 3 - To be filled out by contractor "decontaminating tank": N IA- <br />Tank <br />sTank Decontamination Contractor: <br />B <br />i»ivitttRi»i»vsYtiitYrtrt <br />Ki $ F -it -4, ZZ M61 � 9 <br />� �tzp.Gt.�OU.s 4�l Va 5� <br />Address: City: Zip: <br />Phone #:( <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner as required by Cal EPA. <br />Title: <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or coosal facility <br />accepting tank and/or piping. 1 <br />Facility Name: /'7 /7(c5//�/0 -S r,<y1C6e <br />i <br />Address: 2212 G�IIA [J. t4/A1 C%r" City: C::5 Zip: '9fZ//0-7 <br />Phone #: <br />Date Tank Received: <br />Signature: Title: <br />EH 23 049 (Revised 7-10-92) Page 10 <br />