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E <br />UNDERGROUND #',' DISPOSITION TRACKING RECORD <br />Public HealthServicesTracking Sheet will accompany"twith Its site Identificationnumber. <br />The Tracking Sheet 1 1' returned Public Serviceswithig daysofacceptanceofthe tank1thedisposal or <br />recycling The permit r t 'i i responsible i' ensuring: this form is completed I 1.returned. <br />FACILITY NAME: <br />TANK !a Description: <br />SEMONbe Mod out by o <br />Tank Removal <br />Address: City. <br />Zip: <br />Phone : Date Tank e <br />SECTION filledw co , <br />Tank Decontamination C1t ii" <br />Address: City: <br />Zip: <br />Phone : <br />Authorized representative of contractor certifying through signature 1 that the tank has n decontaminated in an <br />approved required ,by Cal P <br />Si ature: Title: <br />SE - To be signed t an authorized representativeof the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: City: Zip: <br />Phone : <br />Date Tank Received: <br />Signature: Title: <br />EH 23 049 Levis 7-1-2) Page 10 <br />