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SAN avAQUIN COUNTY PUBLIC HEALTH SEi.✓ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />q-ANK-ID-09= 10 F' 1t -AC-, T*NfE SIZE: 21, PREVIOUS TANK CONTENTS:��- <br />PI1P Irih <br />SECTION 2 - To be filled out by4anc removal contractor: <br />Tank Removal Contractor: �kj r__ 0407_ <br />Address: p• D � 1E> -0x (+O3 <br />Pt p;--- <br />Phone #: O S`-' ��10 Date T4nk Removed: <br />City: LDO1 CA Zip: 0-�)t52A- t <br />SECTION 3 - To be filled out by contractor "decontaminating WmW,' s <br />Tank Decontamination Contractor: �N e M UT— <QA a - <br />Address: p D . PjOx 14-0,3 City: Loo 1 , Gilk Zip: q S2+ , <br />Phone #: <br />p�P� <br />Authorized representative of contractor certifying through signature below that the4ank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name <br />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: <br />Address: <br />Phone #: ( )_ <br />Date Tank Received: <br />Name: Title: <br />City: <br />Zip: <br />Signature: Date <br />EH 23 046 (Revised 08/13/99) Page 10 <br />