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UNDERGROUND STORAGE TANK DISPOSITION TRACIONG RECORD <br />te <br />dentification number. <br />SECTION 1 -Public Health Services tTracking <br />p bhc Sheet Heal will <br />Services withinaccompany 3® days of acceptance ofaffixed with its lthettank by the disposal or <br />The Tracking Sheet is to be returned <br />able for ensuring that this form is completed and returned. <br />recycling facility. The permit holder is respons <br />FACILITY NAME: U O O A1-- <br />FACILITY ADDRESS: L -"i o i v✓ <br />TANK ID #39 - <br />Tank Description: I2 e- <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />City: �P <br />Address: <br />Phone • (_� Date Tank Removed: <br />SECTION 3 - To be filled out by contractor 'decontaminating tank <br />Tank Decontamination Contractor - <br />City:_ <br />Address: <br />Phone : (------ ,, <br />ough signature below that the tank has been decontaminated in an <br />Authorized representative of contractor certifying thr <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: gyp' <br />Address: <br />Phone #: (_ _ <br />Date Tank Received: <br />Title: <br />Signature: <br />EH 23 049 (Revised 7-10-92) <br />Page 10 <br />