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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />liilY!###Y##iiiiltiiiYY!!#Y!i#i!##!f#t!!!!Y#liii####Y##i####i##i#i#!!iY!liiiiiiitiiiiYi##liiii##YYilYiiiiii <br />SECTION 1 - Public Health Services Tracking 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: S14e-c <br />k- <br />1,:�;r12t1x c7 <br />S i19-T/vA) <br />FACILITY ADDRESS: 3'ff <br />614a,,7- <br />171141 t� <br />5 <br />M; L -e -' . R 1 tuk) <br />TANK ID #39 - Tank Description: <br />SECTION 2 - To be filled out by tank removal contractor. <br />Tank Removal Contractor. <br />Address: City: Zip: <br />Phone #: ( Date Tank Removed: <br />SECTION 3 - To be filled out by contractor 'decontaminating tank": <br />Tank Decontamination`L Contractor. ne��y + c��` I� '!U L -.- <br />Address: /' 1 / City: n6 j . ]� Zip: <br />Phone #: ( SIC) ) 6 '� —0 `13 (,, <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: <br />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 piping <br />Facility Name: IRR[CAC-SCK� TNC <br />Address: 2j5 -s- L�?R' 1- V I) • City: .XC14 Zip: 9 4foo l <br />Phone #: ( ) '2- -�> 15 — 1 --2--)c <br />Date Tank Received: <br />Signature: <br />Title: <br />EH 23 049 (Revised 7-10-92) Page 10 <br />