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SAI )AQUIN COUNTY PUBLIC HEALTH S1 ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 dans 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 returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39 - <br />TANK SIZE: <br />SECTION 2 - To be filled out by 4 %k removal contractor: <br />-Pr,, <br />Tm* Removal Contractor: L C, S C:2v :'cE_S <br />PREVIOUS TANK CONTENTS: <br />Address: -5-2 7 A-11PN& 1C V 4"F 6—. City: Rr ,S.ti C! Zip: `!'.3 7 <br />E <br />Phone #: (S�;-I) liq q ` 17.3 O Date Tapk Removed: <br />SECTION 3 - To be fitted out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: ( ) <br />City: <br />Zip: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name <br />Title: <br />Signature: <br />Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting termer piping. <br />Facility Name: i�-Ct)joqv_Carv. 2u .Jcl.�s i ►2 •'x r <br />Address: 137,3 8J OVV E2 AV <br />Phone #: ( 96 9 ) 315-- <br />Pi D;-Nej <br />Date �a"Received: <br />Name: <br />Title: <br />City:_re,,,—, A, A Zip: 9 2 33.5._ <br />Signature: <br />EH 23 046 (Revised 08113/99) Page 10 <br />Date <br />