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I 't • RIMS MIK• ! <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 within 30 days 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: \i <br />MWI 4i1M'e � Ia)r0i�.Y. <br />TANK M #39 - <br />Tank Description: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: ( M <br />Address: City: <br />Phone #: U Date Tank Removed: <br />Zip: <br />***m*�**.*�**a**ss*as*ass*mx�u�a:*assesssee*e•s*�**a•*.s�s�e*:*sse�s***�•r**•as.***:...�**�***s:*•s•�:::xss�� <br />SECTION 3 - To be filled out by contractor 'decontaminating <br />Tank Decontamination Contractor: G -e <br />Address: 84-'300 : u r, . ► ' 4 <br />Phone #: 6 3 <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 />Signature: <br />PA <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: <br />Phone #: Q_} — Lan <br />Date Tank Received: <br />Signature: Title: <br />EH 23 049 (Revised 7-10-92) Page 10 <br />