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�# SAN. iA%OIN COUNTY PUBLIC HEALTH SEI. -uo <br />ENVIRONMENTAL HEALTH DMSION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />#}itr#fi<ttii####!4r#rt}#!fi##!}}##}}}#}}}}►}}fifi###trt##i##rt##}MMMT}ttt4f4ttlti#rtrt1#trMrtlMt!#1;ifirtfiifrt#MMltrtififi <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />r 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 reypaed. <br />` FACILITY <br />FACILITY <br />101000, -LIoAon <br />TANK ID #39 - TANK SIZE: I r,,c .,g /Xl Inn PREVIOUS TANK <br />rfifirtfirtrrt}fiii+!}lrrfit}rrt+}r+rfi4rtlrtrt+r+r#4firtfi}firtfiltrti#fiir+rt!}r+}+firrtfirt!}»#+»».»4»»»#»»».rrrrrr44»r»+»»#»»4r4r <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: R A t)A fv(eD 6 e D G i r0 o rr air I <br />Address: 4005 N. W, 150 n IAEA IT City: S%<_K I ofd Zip: 9 52c�:� <br />.# Phone #: (x9 1 ) �A / I1 O �O Date Tank <br />#}+##ir4t4+t#44444!4##4rf Vt4#++}}fi#44444###i++#+4rtrt4i+<!}#<#}+#rt4+rt4444fi•rr4rfirt+4####444+f+i444#444##rt444r} <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address-. q (o o(( W I �So f') Wl a `{ Ciry: 5 Tb S On n Zip: 952-3 <br />Phone #: ( R ) y b % <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />` Name: Title: Signature: Date <br /><fi#4#}ltit#!}++firt#ififi44trt4+}fil+fitfit#fi#4rt#fi+++ifi#+irtiirt!##4111!}4ifi4fi+rtfi+}+Mi########trtMfiififii##ifitfi##}4Mfi### <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: P. I GQ CX 2 3 (n F -City: 1 y f le (k Zip: 5s(� I <br />Phone K: (Zc CA ) '(j 6 () —9 � 7 F <br />Date Tank <br />Name: Title: Signature: <br />!#llfirrr}##!fi!#!!►+fiifi##tM}!!!!}}#44444#fi#r+rttll44rtt4fifi}#!fi}!4!!!rtt!#fir#r!114+4!#it!}!!!<fifi!!!!rt#!!!M4}! <br />EH 23 046 (Revised 10/19/98) Page 10 <br />