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• <br />• <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />!i!liiilifiilfftif;ittittifli!!t!!#f!i!!tt!littltlitiiilllift!ifliflfltlfY!lifffliliilfitilfiflifiiiiiiifi! <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 />FAciLrrYQ• <br />TANK ID #39 - / ? 6 � C- -�;) Tank Descriptio <br />w <br />Z Pulo�S" (4- <br />Riififii!liifiiiilfist!iilfttlffifttiltlsfititltif;iffatiiffifliit!!i#liftliiififlifltiiiiiY!lfitiitti;f♦ <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. / ',a-, . <br />61 0 <br />Address: P O- BOX 79-/5- City: C/)eou G Zip: 95- 6, 4!� <br />Phone #: ( V4 ) (SS - .3/8/ Date Tank Removed: <br />sss;sr#lYsrs!riffs;sist!lsssaasasfassrtarssssifsfffffartsfsftsftfssatfsastsrs;sfassaets:aafsfsstsasresfssfe <br />SECTION 3 - To be filled out by contractor 'decontaminating tank": <br />Tank Decontamination Contractor. W i h G . <br />PT <br />Address: RI O , $ O X � /S City: 6-,e o v c Zip: JS�6 8 <br />Phone #: ( 9/bl )_ _ (55-s- — -3 / 8 <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 />tf iltlilii!!!i!f!f!!!f Yltf tlf!!tltfi;tltittt;iifffliiiltii!lfYtfflit!Ylfiilitfilitlffliiti;ff;!!filYiiittlt <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: F- Q i c `C- S b n <br />Address: _a 57,5- Pa rz R_ ?) t vd . City: (2 c ,nn o Zip: <br />Phone #:(,510 ) oZ 3 - — /3 q3 <br />Date Tank Received: <br />Signature: <br />Title: <br />tffiffliY;Yfftrtffifl'i RttfiYtii ff tfffYti!liffi;rf;if iiftsiitffiffft Rf Yiffiffffiftft;iifaif;iafffiltRt iff <br />EH 23 049 (Revised 7-10-92) Paye 10 <br />