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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> )� CTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br /> cling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: 1N.141'1011117I I11 11 <br /> 11pp__.. <br /> FACILITY ADDRESS: 5 b0z) tm t IDhYI C- q53u(0 <br /> TANK ID #39 - Tank Description: o21 LT CJ Q41�1 l 1111` <br /> ..••.•.•,.•••.•.....••.•...•.•..•............................•.•.•......•,..,•••...•.....•...••......•..,.. <br /> SECTION 2 - To be filled out bYlnk removal contractor: �l' <br /> Tank Removal <br /> �'C-oontraactttor. �I(�111({�<} �X(��-}jVA OD �/" <br /> Address: o(.Uf"I v%or) U t City: Zip: . Q_5j5f p <br /> Phone #: ( �Dq ) bqq-0'N-7 Date Tank Removed: <br /> ....................•.•...•.•.,,,....•••......,.......•..........,.............................•........••. <br /> SECTION 3 - To be filled out by contractK decontaminating tank": ^. <br /> Tank Decontamination Contractor: d1Y-f' 1a'CIII6-fiti lD Th Q_ <br /> Address: .Qbq (�YPGCt1 �iI City: 6 Zip: 61t—adp <br /> Phone #: ( �Rq- X34 I <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as requir� Cal <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: 'l al— <br /> Address:_ I5gc) Lynwood City-014n Zip: q53Q(_P <br /> Phone #: ( o ) b d— q3&9 <br /> Date Tank Received: .--� 'C` <br /> Signature: e�L7 <br /> Title: <br /> EN 23 O49 (Revised 7.10.92) Page 10 <br />