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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> •..ft...f.....f.a.........f....tf.f.alit..M....a.f.....iff..t..t............i..t.....i.................. <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 /> ible far ensuring that this form is completed and returned <br /> recycling facility. The permit holder is respons <br /> FACILITY NAME: U r1 o CL A i— eb !7 <br /> FACILITY ADDRESS: 2'l o v✓ 411-1 <br /> TANK M *39 , Tank Description: 12 00o ev+ . 8'k o e_ aµ� "e, <br /> •.aaaaiafl...i.i,.,eii.....r.tl........1....riw.rt..t.ala......auaaaii.aa•.......io.a. <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 /> .aaa.a..sa....aaaa.......0...................r.t...w....a.aa..w.w.i...as ova..aa aw.o <br /> 9twfION 3 -To be filled out by contractor'decontaminating tank': <br /> Tank Decontamination Contractor. <br /> City Zip <br /> Address: <br /> Phone #: ( <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA <br /> Title: <br /> Signature: <br /> ..,........i.....i..l....,i...i,.l.......till.,.ii.i.....i..t....t.i......,i..i..,f...i,....i.t....r......i <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 /> Faciliry Name: <br /> Ckty Zap: <br /> Address: <br /> Phone #: <br /> Date Tank Received: <br /> Title: <br /> `CO3mature: <br /> v.a.u.alaa waaa.......sa.au.uaa.. .....aa.a.u...auiaaau.oaas,aa.w <br /> .EN 23 049 (Revised 7-70-92) <br /> Page 10 <br />