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0 • <br />UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD <br />SECTION 1 -Public Health Servltxs Tracking Sheet <br />The Tracking Sheet is will accompany each tank affixed with its site identification number. <br />to be returned to Public Health Services with 30 days of acceptance of the tank by the disposal or <br />recycling facility, The Permit holder Is responsible for ensuringthat <br />� � this form Is completed and returned. <br />FACA.dIY NAME:—.� 'L-1,20 E 10011 I <br />FACULTY ADDRFsc, i I-,--) I TA , <br />TANK ID N39 - __L6jfB _O -L Tank <br />Description: (C)t toOyTc <br />••...••................................................•.............1...................... •.............. <br />SECTION 2 - To be filled out by tank remova�contractor. <br />Tank Removal Contractor_ P - Ll. <br />Phone #: y(I _ 0 ( 1 <br />— Date Tank <br />City:(ti(ngl <br />Removed: 9 - 2!j _ 3 <br />•............•...............•...,......................................t................... 4 ........ <br />SECTION 3 - To be filled out by contractor 'decontaminating tank': <br />Tank Decontaminatlon Contract., /1. <br />i0 <br />Phone *: <br />7-(Lf-_rALN <br />Authorized reprtive of contractor certi <br />approved stunner through signature below that the tank has been decontaminated In an <br />/a} <br />Title: � �— <br />SECTION 4 - To be signed and dated <br />by aauthorized <br />accepting tank and/or piping, "Presentative of the treatment, storage, or disposal facility <br />- <br />Facility Name -'till k�10riA —rte <br />Address: I C <br />City MFl—�_ Zip: 91�( OOH <br />Phone *: Cf&� 1 (d, 1 - 2e , i <br />Date Tank Reoved 9 <br />Title: L )Ic ev�,:;l 0041 T <br />ER 23 069 (Rwiead 7.10.92) <br />Pep. 10 <br />�i <br />