Laserfiche WebLink
I <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .•••..•••••r••••r••04•••••••••000.0000•••••NH•NHH••••••••••••••••N••010••••••••r•0••000••••.•••r.•... <br /> SECTION 1 - Public Health Services TraPking Sheet will accompany each tank affixed with its site identification number. <br /> 'fhc Tracking Sheet Is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposA or <br /> recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME:.S2" /z'F tJ,,/// r'/, ✓/ I* -Z;fl- 55ZIVL. _1 --.- <br /> FACILITY ADDRESS:���C} /VCS C �Gc�Ri./i, <: '�/Ge/CTVA --- <br /> 'TANK ID #39 - �0 L I Tank Description: � y; �� L�� F�,f----• <br /> SECTION 2 - To be filled out by tank,remov�l co w /�C� ✓i �� /, <br /> 'rank Removal Contractor: ETC A✓ -- <br /> Address: 7--,n 2—�.% ti/��rc> ��.-f— City: tip: `5-��-dl<'�_._ <br /> Phone #: Date Tank Removed: —_ <br /> ..............••r.••••••••••r•••r•••r•r••r•••••••••••••••r•rr•r••u•r•••••••r...•rr•r••.................... <br /> SECTION 3 -To be filled out by contractor 'd ntamin`g tank': <br /> Tank Decontamination Contractor SI C�lC �I% �'�� � �Z�'r <br /> �/ 1 <br /> ZIp: '- <br /> �-G�•- ..--- <br /> A �l j <br /> " Phone #: (� 3 I R <br /> r <br /> Authorizer resents or certifying through signature below that the tank has been decontaminated In an <br /> v' approved r red by EPA. <br /> I Titles <br /> Signature: <br /> APP SliCrlON 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> :Ax accepting tank and/or piping. <br /> ITE <br /> us. <br /> I C 1'acillt <br /> Y.P <br /> Address: <br /> Pr I i► ..-.._ ._ <br /> Phone #: <br /> i)ate 'rank Receiv <br /> -_ Title: ..--- <br /> Signature: <br /> .....•. .• ••••••••r r••••••r•••••••••••••••••rr.•••••.•..•••••r•.r••••.•••.r••.•••••..r.••.0...000••.. <br /> 04eP.O• to <br /> EN 23 O49 (R•vl••d 7-10.92) <br />