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SAN t COUNTY PUBLIC HEALTH <br />ENVIRONMENTAL HEALTH DIVISION <br />########################################################################################################### <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: i�E"�T1xt" l PA<�k � <br />FACILITY ADDRESS: !�201 vETrLa M1� L-�3t� �! G�'` `3l <br />TANK ID #39 - TANK SIZE: 4�it • PREVIOUS TANK CONTENTS: �\4aSTE o` <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: c06`�"Cr_rt M <br />Address: p ®• O?� City: Zip: <br />Phone #: (203 )�F•% • Date Tank Removed:' 13 8 ✓R% <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: ry-" <br />Address:-�li� CityGCII 7 Zip: <br />Phone #: ( 610 ) -2 1 t `j 3 -- <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: ` Vic, n, <br />Address: �� �� �� CityPA6*WATD Zip: <br />Phone #: 05 ( b) <br />Date Tank Received: <br />Name: — Title: <br />Signature: <br />EH 23 046 (Revised 9/11/96) Page 10 <br />Date <br />