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SAIN kQUIN COUNTY PUBLIC HEALTH SEF 'ES <br />ENVIRONMII�4TAL 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 Trackin; 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: r4�% <br />FACILITY ADDRESS: S7� CL�tS� Cr/�yti�jc�e� 2A 7iw!4 /_�It f5-077,,/ <br />TANK ID #39 - Wo/' TANK SIZE: 5 PREVIOUS TANK CONTENTS: �iZyoJhG <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: �Ya ! Ji �►G�S <br />address: city: � zip: <br />Phone #: (,;�7g ) �a6 " �✓r�� Date Tank Removed: <br />-------------- <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tanis Decontamination Contractor*� <br />Address: � — City: Q�,: Zip: <br />Phone #: `' ) �o?� - �✓�� <br />Authorized rep native con ctor certifying through signature below thaZLheh been con ated in an approved <br />M, <br />as r ed by al EP <br />Name �" LSI ''C ����Signatu Date 7 <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: J 6h ,hM',0 �D/Uf7a» S <br />Address: A ab Zip: 2 33 /,� <br />Phone /t: (is C0 () " <br />Date Tank Received: 0I <br />Name:lJoEWE"A)MEL-&M Title: SVSSCIjEbyi-gnar ILr �_U_Qate G`% 0� `1 <br />SUPER_v L's c2 <br />EH 23 046 (Revised 10/ 19/98) Page 10 <br />