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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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:_ C—�//�! j eo/) u �ng( <br /> FACILITY ADDRESS: -5 75 Co p da a <br /> TANK ID #39 - � �� Tank Description: <br /> .....s....r,.....r......ru.x•w..as...w.s,u.....uu...ra.uwxw.w,xs..a v................................. <br /> SECTION 2 - To be filled out by re o 1 con[ ctor. <br /> Tank Removal Contractor. l 7C� <br /> Address: Cnii/d Ciry:Zi/Jeesnktc zip: <br /> Phone #: (J" /V ) ��� ��b `7 Date Tank Removed: <br /> .......,orrru...„tar,.e+.rs.w+....xr+..•,.xx..+...,...,.s.,xw.•sss,wx..rr,,,xx.r,a,.•w.....,x.w.+,,.,. <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor. <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 /> Signature: Title: <br /> ' ♦v..a sstsuxxausauv...s,ow.,..w..ua..a,,a..sa,.s...++.,..w.•s..w,w+r„s.x..uxxrs»ssax.rs,•. <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: COc-�cJL<f � <br /> Address: h ?714�1 ( 94/vel <br /> Phone #: 611Z) , r-2 50 <br /> Date Tank Received: <br /> Si¢nature: Title: <br /> ....,.............................x.x............,,.................................,,.................. <br /> -4 23 049 (Revised 7-10-92) Page 10 <br />