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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - Public Health Services Tracking Sheet will accompany each tank atTixed with Its site identification number. <br /> The Ttackbng Sheet is to be returned to Public Health Services within 30 lova of acceptance of the tank by the disposal or <br /> ung facilitY- The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACULTY NAME:�1� 77�� <br /> FACILITY ADDRESS: <br /> TANK ID #39- ,r' —G6 Tank Description <br /> •................a.u......aa.,..,...•u.......•u.v...a..•..,..,.a...u.a.....a.o.....� •,.,us.,aa,..• <br /> SECTION S -To be billed out by tank removal contractor. <br /> Tar' Zemoval Contractor. / S f <br /> Address:_ (y X A `S F C�+Ci <br /> ty 'C Zip:_ � <br /> Phone #: 5(�� 1 y c� cZL�c/[J Date Tank Removed- <br /> ...................................—...-.-...........,......,..................•............................... <br /> SECTION 3-To be billed out by contractor*decontaminating tank': <br /> Tank Decontamination Contractor. <br /> Address j l=,ti �( n' at tJ-errvte(2zip: <br /> Phone#- ^ u f <br /> Auth0I representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manna as required d by Cal EPA <br /> Signature: <br /> Title: <br /> SECTION 4-To be signed and datad by an authorized representative of the treatment, storage, or disposal facility <br /> accepting malt and/or piping. <br /> Facility Name: <br /> Address: <br /> City tip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: <br /> Title: <br /> EH 23 O49 (Revised 7-10-92) Page 10 <br />