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u ll <br /> AJOT A-PPL i C A-3L E <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ssssss4#sass;•i!•ssfiwssssr4assssissrrs;isaYarlssssslisi#rsYrrsisa/t/!lsiisaliwasisilr!/s#si#ssrsir#tfsssss <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 NAME: <br /> FACILITY ADDRESS/: <br /> TANK ID #39 -50(�C / — d-3rank Description: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. <br /> Address: City: Zip: <br /> Phone #: U Date Tank Removed: <br /> iYiYYtrlliiiwfiYtrll;iiYti!lrl;wfiiYiti/rwlfiiY!/tr;ifii #Sial Mi;#RiwttR;;iwfiwriiiliiiixxi/iii}iiw}#iiiiti; <br /> SECTION 3 - To be filled out by contractor "decontaminatinY/; <br /> Tank Decontamination Contractor. <br /> Address: <br /> City: Zip: <br /> Phone #: <br /> Authorized representative of con ctor certifying ough signature below that the tank has been decontaminated in an <br /> approved manner as required I EPA. <br /> Signature: Title: <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: City. Zip: <br /> Phone #: L� <br /> Date Tank Received: <br /> Signature: Title: <br /> ttt/wrwif Yt/#/;iYwifi#riififiYirr;i#iYttil;;lli;ii/t!#;#wwii/r;;fiYYiaai#w iia/i/i;liwil Yfw#isrtYl;iswiii <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />