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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD f-% <br /> ' #ttt#t#444###fffiitf4#f tt44it4itt tt#tItl4#4t#44######4t#Rt###tt###4####i ttt Rttfftffi##4ftffft#tfitf#f»itfft <br /> SECTION 1 - PubIic 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 permlt holder is responsible for enstiring that this form is completed and returned. <br /> FACILITY NAME: <br /> rr:• <br /> ' FACILITY ADDRESS: <br /> TANK ID #39 - Tank Description:_ <br /> 1 v <br /> #tt#Ri#RRittittiftf#tt##*#4*i!!*#t####R#4##RRtit#t*4#Rt##t4##tt#####l4«tttt4ttRR4f##*4f t4 ttt4#t#4###f#*4i4# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> ' Tank Removal Contractor: <br /> Address: G l j?' -� fTUG_. City: S )J Zip: 7�/ <br /> Phone #: { ?C l� `t 5�" �_^ Date Tank Removed- <br /> ##t#4tf#ti##f#ttifi#fftff#fR#t4fffiitt44♦Rtlis#��ittitt«stft!»tl4if#••f##*##Iiitttiiit 4t#t#tt#t4tt#ittt•t##t <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: EA.�)es 9r'C'D <br /> Address: r - �f�r7Uf City: < {' p: ~,' <br /> 1 ,, II c r o f.� Z) ��[,I <br /> Phone #: � ( �� --z4n,y, <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 /> } <br /> Signature: '—�' i', f} ` ''�� !.rte'.� Title: . r <br /> f <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: <br /> Pf ��ttx� I / ., �. �,.�.. City: r ^! _ Zip; <br /> _ f <br /> ' Phone #: {; 7 ) <br /> Date Tank Received: <br /> Signature: Title: <br /> ' EH 23 049 (Revised 7-10-92) Page 10 <br /> 1 <br />