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r • • r • r . �, - •Vill <br />• • • <br />SECTION I - 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: SToP -7(o <br />FACILITY ADDRESS: {0 3p S , D(..1 tve ,Avg S Lb G k�N CPr <br />TANK ID #39 - TANK SIZE: 10/ 000 PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: WPI (,TorJ 5�J 6-! 1j /1jEs 1 G <br />B® <br />Address: ` <br />Po , City: LA), 5A-C� zip: <br />� I ca <br />s- <br />#: (4 ! �) 31 _ c �'�' Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: WAL-r.J %vim <br />Address: ('b �U?= (a2S City: t/�. S�4 Zip: <br />Phone #: ( T ( ) `? -%--,;, s` t (.,g <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: <br />Title: Signature: Dace <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: W557 Ce:hAg &;zvtPM "T <br />Address: <br />�j 4 0 �° L- R) W 60D City: -rol .1,0 c K Zip; 4 ✓ 3 80 <br />Phone #: ( 2�) �C' q 3 / <br />Date Tank Received:, <br />Name: Title: <br />EH 23 046 (Revised 7/10/96) <br />Signature: - Date <br />Page 10 (b) <br />