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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ••••rur•r••„r,,,r•r•.r rrrrr•rr rrrrrir•rrrrrtrr.rt.rrrrrr..rrir•rrrr.r,r.rrr•r•rr,rrr••rr•••.,•.•i„•1.•.. SECTION 1 - Public Health Services Trafking Sheet will accompany each tank affixed with Its site Identification number. The Tracking Sheet is to be returned to Public Health Services)within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITYNAME;�7 Jz" f'n.{/` <l`_r`_,t/l1-✓io��1/_ f7�-7,� FACILITY ADDRESS: TANK ID #39 - iyG i - of Tank Description:_ Cowl ••••r•••r••irrririr•i••irrrirrrrriirrrrriiiirrirrririrrrrirrirrrriirriii•rrrrrir••i•ir,i••,r•••,•••r•••.•.. SECTION 2 - To be filled out by tank removal cog;rect r. Tank Removal Contractor: - TO-v Address: 7>-C', n . (s(,2-)'/el 6 City:Phone #:#: Date Tank Removed: .•••.•••••r•••••r••••r•••r•••rrrrr••rrrrrrii••iNrrrrrr•i••••rr•r•••r••ur•rrrrr•,r•••,••••••••••••:••.••.. SECTION 3 - To be filled out by contractor 'doep°ontaminatiag leak': 'funk Decontamination �Contractor:—S1 o�/C:1>V Address:.co) E'er' /,I D . ffrF,r Clty c � CLL i 71p:CjS 2(/, Phone #: ( Authorizer resents ' or certifying through signature below that the tank has been decontaminated In an approved r red by EPA Signature: Title:- .••.••r••••••••••,•r••••r••••••iii•i••r••ri•ir•r•n•rrrr••r„••r•ilii•rr•,rrr•••r,urr•i•••••r•••••r•.... .. SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or /)piping. Facility Name:�/`�,c_.,E% yf." J� .,.,[ // Address: / ilo /(.[& . L l/Le•' �t� 1��r^ _ City:�y-<f'-eA-) Zip: Phone #: Z, L&' %, 5 .....- -- Dace Tank Received: Signature: Title: ...r••.•••,•••••••.,••••rrr••••rr,r•rrrrrr.•♦igrrrnrr•irrrr•••i r�i••r•••••••••••ru••.••••u.•••..••.. Ln 23 049 (Revised 7.10-92) Pepe 10