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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - 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 days 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 /> FAC[LIT'Y NAME: <br /> FACILITY ADDRESS:, 64, f /1 r( 3 --`:4 VI <br /> TANK ID #39 - Tank Description: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: A� mor <br /> Address: f.j'ZO del. Lf t o s S'!- City- c�-For zip: QSZOS <br /> Phone #: 81333 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank' <br /> Tank Decontamination Contractor c <br /> ✓ � y`- . azip: <br /> Address: <br /> Phone #: C� ) <br /> Authorized representativ of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved m requ ed by Cal EPA. <br /> Signature: -- Title: if <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� E ,A1- ¢YritJrrri�S <br /> Address: �2Wn Alf ,, �Jr t ' City,<-�t�eK-roN Zip; <br /> Phone #: '� �yry —_2 2, <br /> Date Tarrlc-ireceived:,? • 2 s <br /> Signature: ,4 ^ ` ,,–, Title: <br /> ' EH 23 049 (Revised 7-10-92) Page 10 j <br />