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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> atrYtiitf Yfittti+aitlitY+tatrir+i��irfi+YiYtYt++Y+Yawiairtrt...Y+xtr+ra+i+x.....rltt Ytr+x+w+rta.Yiwiwr+xrt! <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> vices within 30 days The Tracking Sheets is t orbs returned hoto Public is respon Health Ser <br /> for ensuring that �f completed antance of d returned. <br /> turned e tank y the disposal or <br /> recycling facility. The <br /> FACILITY NAME: <br /> tjO 1 5 8 a t� <br /> FACILITY ADDRESS: 2w b M <br /> L-, - GrM� <br /> TANK ID #39 - Tank Description: 1 O cxx� o �o <br /> iY ✓I <br /> uuuafiu wu ualiuuuuutui+iulilxuuruuauuruuwuuuu+uuttuxrau uuY+utura allot uta <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: <br /> City. Zip' <br /> Address: <br /> Phone #' (_� Date Tank Removed: <br /> a uuuxriJ i+tlu iuif iitrxiuioruur+tuiartuautlututuraary <br /> turx.wlwrtwtuitultlrwr+vuuuu <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor. <br /> City: Zip: <br /> Address: <br /> Phone #: ( <br /> r certifying through signature below that the tank has been decontaminated in an <br /> Authorized representative of contracto <br /> approved manner as required by Cal EPA. <br /> Title: <br /> Signature- <br /> +alum <br /> aat uralttiluauuali utuuttuiuwiuttaw+wlxrratxiiriruluxt+utuuutxrY+YrruaiYtxxrtuxr <br /> u <br /> of the treatment, storage, or disposal facility <br /> SECTION 4 - To be signed and dated by an authorized representative <br /> accepting tank and/or piping. <br /> Facility Name: <br /> City- Zip' <br /> Address: <br /> Phone #: <br /> Date Tank Received: <br /> Title: <br /> mature: <br /> aarlux <br /> �trYr+taifftuuauuuutuxuuufau+uw+wara............ utruaua+u rrurr wrxwa rriu+atxu <br /> '.Ex 23 049 (Revised 7-10-92) <br /> Page 10 <br />