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SAN AUIId COUNTY PUBLIC HEALTH SERV4)S <br />R;VIRONAENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />............».........».................»...».,............».......».»».................................... <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sbeet is to be retttrncd to Public Health Services Envirotunental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and <br />�r^eru/rned.MINI <br />I A I ,� �7 <br />FACILITY NkME: M I M I I ";! I Al T <br />FACILITY ADDRESS: I 1-17 (0 Q1 I& I (., v" '�� _ _ <br />TANK ID #39 - �3G�" ( TANK SIZE: 101 MO PREVIOUS TANK CONTENTS: <br />..»............u».............................................................................»........... <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Phone X: (� Q27—/666 Date Tank Removed: <br />...... ......... t.» ......................................... ........ ».................................. .n... <br />SECTION 3 - To be filled out by contractor "decontaminaring tank": <br />Tank Decontamination <br />Ciry: <br />Phone k: <br />Authorized representative of contractor certifying through sicature below that the tan/: has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Title: <br />.......»...»,...».»................................... ............... ......... ...w .............. ....n...... <br />SECTION 4 - To be signed and dated by zn authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: l�Ut /�jG�C _� City: Zip, <br />Phone #: (— <br />Date T <br />Name: <br />..».»..........».»»u.....».»»........».................»............»................ 0.u.... 0 ... ..... t <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Phone X: (� Q27—/666 Date Tank Removed: <br />...... ......... t.» ......................................... ........ ».................................. .n... <br />SECTION 3 - To be filled out by contractor "decontaminaring tank": <br />Tank Decontamination <br />Ciry: <br />Phone k: <br />Authorized representative of contractor certifying through sicature below that the tan/: has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Title: <br />.......»...»,...».»................................... ............... ......... ...w .............. ....n...... <br />SECTION 4 - To be signed and dated by zn authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: l�Ut /�jG�C _� City: Zip, <br />Phone #: (— <br />Date T <br />Name: <br />..».»..........».»»u.....».»»........».................»............»................ 0.u.... 0 ... ..... t <br />EH 23 046 (Revised 10/19/98) Page 10 <br />