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UNnMCkoUNU no'it.ACi;TASK ll1SpOSi'1'ION TRACKJNG R1;CORD <br /> kk wtrwllwrk*f♦**rt#t!#if*#rt*trttRttlt*wf***$****t*kt#iif#4 <br /> ' * tRktti##t*#t+••+�Health <br /> ser F Tracking She4t will sc�mPany each tank aMxed with its site Identification numbor. <br /> gEMON I - public HealW services of acooptance of the tank by the dispwAl Of <br /> 'Phm Tnadq Sheet is to bo rcturned t4 Public Mealth S,ery=�` <br /> ruing facility. The paean holder Li responsible for ensuring that thls term 1s completed and tetar>xed. <br /> ' R , ALX <br /> FACTL TY NAME: <br /> 1 ! I '�1�r✓r <br /> FACT1.CI'Y ADDR2$St <br /> TANK UD #34• <br /> l 'rank Ua+4ript3on: 7 IN <br /> ' t*tstAttrtt«ttltt# lsttt#Rtt0*4`**tktlktrtllkFkrt•k*tr#tttw!##t*kklklF4tw##w*#tkk4rktt <br /> SECTION 2 -Tp be 11110d out bywk f0mov ainr: ..----,---�-�- <br /> Tank Re OV81 C;Onttactar: <br /> ' Phone { UatC Tank Removed; <br /> •k#tktwt#tt#4tikk#`tttitt#*t#trt##w�rtrt#t•*#**t**krt•*tk*to t4M••*rt**+4wlf*fkfw60****6 lww#f#*kkkkkkt**#4kMIFtk# <br /> SkMQN 3 - To be 911W out by contractor "decontantiWing tank": <br /> ' Tarek Vowntsminadon fiOatfsctor: <br /> Addrefis: r <br /> Phone <br /> Authorized rcproaantativn of contractor certifying through sigs'taturc hclo ' that tho tank hm been cieconzars}inated in an <br /> ' approved rttattnar as roquirod by Cal EPA,. <br /> Si�natur+a' <br /> ' tt�Rw}##*I�kkktR#tfiklftw#kkft*l�kkk�k*kR#k!!ii!*#tt#rti�#i#��kR#tf�**1�t*�*Rk**rt�w**f4kswt3 <br /> ktY�lt�l�ft�Ft��it�'�1 <br /> ' <br /> aft uutltorized representattva of the treatment, storage, or disposal facility <br /> SEMON 4 -To be 4" and datod by <br /> acroptin.g tams andlor piping. <br /> Facility Name _ <br /> ---- <br /> Address1 <br /> `hone # ` <br /> Date`Cants Resew ' <br /> Titles lG_ E <br /> Signature: <br /> �'#tt4Flk*k0kti►#t*k#*•kkwtwkkF�Rtt1FFlFFtt**ti+tt►k*F*kwflFfR'�kFlkkkkFF*ItfffRfRkw1'fM*#RkklfF�#tt*#wwlrtw <br /> ' EN a3 049 (R&YUad 7-10.92) Peq• 10 <br /> • <br /> 1 <br />