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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD F' <br /> #•r#sttltst444sttsts*rst4rrrst!!**sr*rEssr##srlr#rt#tr#s#ss4isr#s4trrssrr4lrr•#rsss*#sr*sssstrrts#*ssstssss <br /> SEC`T'ION T - 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 dans 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: <br /> FACILITY ADDRESS: <br /> TANK ID #39 - `Z Cr-0�- Tank Description: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: -F"- <br /> Address: y �}:r-`sl:'JtJCity:_ /� �� _ Zip: q&.701 <br /> Phone #: ( ) `t ` ' =`'` '-^ Date Tank Removed: <br /> *sss*strsssttsssst4srs*sstr4r*s4rrrsEss*♦rrrsrtrsi*#*r*trtr4*##Etrs*rrrr4r4rrr4E4ssssrsrr•##ssss4r•rsss4sss <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: 14A1es q�lcv <br /> Address: t _ �t'�r: 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 /> .V U.Signature: '`_-r`�.r: -' ! rF Title: <br /> tii4t44rtttt4tt#**!####tREti4t*ii*#**4t*t44irrtEt lir!*t#*ss44srit*sstttlit*ss4s#ririrRtt4r##t44###*rsEtssrs <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 /> 'r�:r� (gty; !r"'`,s'' Zip: <br /> Phone <br /> Date Tank Received: <br /> Signature: Title: <br /> #it#RR*#rtttitt**ttt#Cirri!ltiititl4ltt*rrr4Eittttlrt*ttE#4rtt##r#ttttrt#!rt***i4#ir*itttltt#*ii*i4#RRR4 <br /> EH 2.j' 049 (Revised 7-10-92) Page 10 <br />