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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> :s###sss#s:sss::ssssss::ssss:sssssss::ssssss*##:sssssssss:ss:s##ssss::::::s:s::s::#sssssssss::ssss:::::::## <br /> SECTION 1 -Public Health Services Tracing 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 /> recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: c-;iNSbL i O r- <br /> FACILITY ADDRESS: 4-0I V� CST KF—:M /-(A 1\J L A f.� t✓ <br /> TANK ID #39- Tank Description: <br /> #::###ssss#ss:ssss::##s#ssa#::ssss:::::ssss:sss####ss#sss:s::::::ssss:s#sssssssssss#s#s#:ssssss:###:::##s## <br /> SECTION 2 -To be filled out by tank removal contractor. <br /> Tank Removal Contractor j rnwa( uc-rI©t <br /> Address: -I ZVV rPt!', SHA,"')A l"' City: 1 ,�y(S Zip: 1 3�O <br /> Phone #: Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor. V <br /> MM � i <br /> Address- n I City: Zip: <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 /> Signature: Title: <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or <br /> �`piping. <br /> Facility Name: �(��.SViV <br /> Address: '2-Ss- PA R `�( <br /> p, IJl-�®., City: �1 O�'� b n zip: X4801 <br /> r <br /> Phone #: ( 510 ) 23 5 1393 <br /> Date Tank Received: <br /> Signature: Title: <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />