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04-21-93 11:39AM P09 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ♦a,p•.lH.N•ds Hi..lH tads•H.H..H.ds.dsdsP.H..dsdsdsi....ds,H.Ni.LHdsds..1 N..lLIIds.•ds.NMds <br /> SSCPEON I . Public Health Services Tracking Sheet will atmmpany each tank afibmd with Its alta Identification number. <br /> Toe Tfaddng Sheet la to be returned to Public Health Servicet vrt.t I 3a data of acceptance of the tank by the dlapoaat or <br /> recycling facility. Tae paxak holder is responsible for easdring that t b form h complded and returned. <br /> FACILITY NAME k�Ax Ra e�iaan6+Mt r <br /> FACI.ff'YADDRm, Flordlvs jg %scowl twtitrapAM wt1�, (ever �etK� <br /> TANK ID #39• N 1<k Tank D oscriptiorc tCOd gglk n Ake-WA Incl &hoar _ <br /> 1....Ldsds.tdsLf.dsdsds H..NH1ptl...fdsds.ds•HN.1.t.•.dsHgp.sstds.ds.Mu..�ds.ds.iH.H...M Vdsds. <br /> SECCION 3•To be filled out by tank removal contractor: <br /> Tank Removal Contractor. <br /> Address- City:.Zip, <br /> Phone#:(_} Date Tank Removed: <br /> ........ ...............dsp..tu.1LL.........,.....,.....,.............................dsUH.ds.. <br /> SECTION 3 . To be filled out by ocavaaor'decontaminaling tank": <br /> Tank Decontamination Contactor. <br /> Address pry: Zip' <br /> Phone <br /> Authorized representative of contractor certifying through signature below that the tank has been decommmWated in an <br /> approved manner as required by Cal SPA <br /> Slgnatare Tine <br /> •.l••HN.dsdsds.ds.dsl.t.N.H.bb...,dsdsHds,•iI•t......HH..u.. **so.*so H.ds.ds.ds <br /> SECTION a . To be signed and dated by an authorized repreaentallve of the treatment,storage, or disposal facility <br /> accepting tank andbr piping. <br /> Fadluy Name: <br /> Address: City Zip: <br /> Phone M <br /> Date Tank Received: <br /> Slgnalure: Title: <br /> LNtsse.sososolso iso H•MIH.s1.Hp4..su....s.,ssss*to Is .p.•t•.•H•.tau•e sods...!.dsllsodsglHl• <br /> Ea 23 049 tRevlsed 7.10-921 Pana f0 <br />