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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 -Public Health Services Tracking ublic Heal will <br />waccompithiny n 0 days och tank f acceped tance of theth its site ta k by the disposal or <br />ntification number. <br />The Tracking Sheet is to be returned <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: <br />t'1 iJ0 C'X- I, ° - '� . <br />FACILITY ADDRESS: 1 b <br />,�1 net - <br />i'e" e - <br />TANK ID #39 - <br />Tank Description: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />City: gyp' <br />Address: <br />Phone #: (,) Date Tank Removed: <br />SECTION 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 />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: <br />City: Zip: <br />Address: <br />Phone <br />Date Tank Received: <br />Title: <br />Signature: <br />,EH 23 049 (Revised 7-10-92) <br />Page 10 <br />