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4� p t-jw%K 4 t� Cd ht-%M oxy' <br /> P � <br /> bpit <br /> jt4FjqA)ejo <br /> UNDERGROL:YD STORAGE TANK DISPOSITION TRAC /RF <br /> aaaaaa.aaa#.a.aaa.aa..............as.si.asa#a;.a;ataasaiaa.ai#aiis.##a i##t..i.isasi#i.#i;i##i#Y.#is#iY.si. <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each to affixed with its site identification number. <br /> The Tracking Sheet is to be returned to Public Health Services within 30 v2I of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensuring that th' orm is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID #39 - Tank Description: <br /> s <br /> •.t.ta..s.s..as.aaawaassataaaa...ta.r#...i.a..i as..#.sa.aa�ra.s.a..ss.-.#s.#i...s...wti#assssuawsaasss.sa <br /> SECTION ; - To be fi!!ed out by tank removal contactor: <br /> Tank Removal Contractor: <br /> Address: City: tip: <br /> Phone #: ( ) Date Removed: <br /> ♦ta.a#.#.Y;i##.##aaastals.tai;..a <br /> us****a t;Y7.=;ii ' <br /> SECTION <br /> na ina 3 - To be filled out by contractor "decontamit V <br /> Tank Decontamination Contrac-or: <br /> Address: City: Z- <br /> 'p: <br /> Phone #: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as requir y Cal EPA. <br /> Sienature• Title: <br /> ts##tas#.a#ss sii iii.# kit#iiiiY#iYi.#.#;isifs#Yi#ii;f####i#i;##ii;#i.###Y###■i#Y;Y;Ys#iii#s# <br /> SECTION 4 - To be sic ed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> acceptir, aft and/or piping. <br /> Facility Name: <br /> Address: <br /> City: tip: <br /> Phone #: <br /> a,nc, <br /> Date A"k Reciived• <br /> Signature: / <br /> Title: <br /> saa.aa#aa#s/�#.Y#sat;sasssassisata#ia.a#a#is.##w####at#aaaa######s.a####.ws.###..#.##sista#;#ii#is#ti##s. <br /> I <br /> E4 23 049 (Revised 7-10-92) <br /> Aare 10 <br />