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SAN *QUIN • HEALTH <br />ENVIRONMIMAL HEALTH DIVISION <br />SECTION 1 - 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 days 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: !^c)a <br />FACILITY ADDRESS: LZ. t of 1 5�o F- �� �-Q-A\ C A, � 8 2, o S <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address:S�� tl\UR gib\ L\1\j \Ong city: 5'C(�L �kO N Zip: � 5 2.) 5 <br />Phone #: (J> (1, 4 - 3 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor:5—t UL L�-�oN S tRv \C -. 5 —� N �)0 til �, �u l N L <br />Address: 0P) City: Sao C )4,'t t3 Zip: g S <br />Phone #: (2 -Q�-) q!94t- A 11 <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: 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 tank and/or piping. <br />Facility Name: _L pal. [Z 0p�� l - 0 l <br />Address: 0 O W\uBZ� City:y�� V C 1` Zip: 2� 5X40 <br />Phone #: ( ) (a Q, - q , - <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />COM <br />