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0 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />sa•aata. sx aaa>aa»a.aaaraa>aaa.saaraxrrrrax»a>arraaaa.asarawaatxaa.asa,,,a>ara r,ar.,>xaxaaaraaxrr.ar.ra•aa <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 />FACILITY <br />FACILITY <br />T? N -K ID m39 - (4 S I -a 1 Tank Description: I0 f 000 6A I i A O w 5e� <br />aa. as..a..aau aaaraasua.asaar.+.>ara.aa»rata.aaaaaaarwa•ra+xaaasa.a.ruaaaa.aaaaaa aara.sa>•rs ra>.auas.. <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: 5 N1C e_ <br />Address: <br />iZll <br />S • 7Tft 5�yceA <br />City- -o Zip: <br />Phone: <br />L( C3� ) <br />SZ�'�1�53 <br />"Modes{ <br />Date Tank Removed: I�. 16,`t`�`� <br />,.•a.. awara.auaaa>aas..aaaaarsaatraaa..aa>arsaraaaaaaxaaraaa..asaawwasaras..wsaaaaxaaawaaa+aa.aa a.r.•.•aaa <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: SEM C 0 <br />Address: I Z l -1 1 i �, Ste --e,4 City: M OCV5�0 Zip: <br />Phone #: (Z0`7 ) 7 44 —(hj 3 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner requ^ired/�by`�Cal <br />'nEPA. 0 / — <br />Signature: A A AI(.tY \ /cella / n2 � �1/1J0'�" Title: <br />a...auaaasaasasaaasaaaaasaaasaasass.aa»asaraasarrra.wstsaxaaraaaaa>xaawaraaswa.x.a.awaraaaaa>ar•... r.a+a <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: 21-1 �, 7 4-4 S4Y P_P_ {" City M 0 CTS S4. Zip: S 3 S <br />Phone #: ( ZCJ 1;Z,44 -1 US 3 <br />Date Tank <br />u <br />Title- <br />........ * <br />itle: <br />........, a.. r.............aarx.sa.asst..a,a,a>a.r.a.rrrr.auara.arata.asaaru.a.aapa,a,.a rru r.a.rar a.a <br />EH 23 049 (Revised 7-10-92) Page 10 <br />