Laserfiche WebLink
FROM, :JIM THORPE OIL FRX NO. :1 209 368 1851 ten/Rpr. 21 2006 09:37AM P2 <br /> 2, o X3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIQNG RECORD <br /> W!r##ltftf#*#3##fiitiiitrtf4t WWW#WWWWW##i*######f#r###wf#»#rWWW*##i###i#w##rw*###i#*rYYYYrt#####YYif# ##rrJ# <br /> SECTION 1- Environmental Health Deparm=t's Tank Tracking Sheet shall accompany each tank affixed with i site <br /> identification number. The Tank Tracking Sheet is to be retumed to the Environmental Health Department within 30 da s of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for enuring that this form a completed <br /> and rctumed. <br /> 17ACILITYNAME, G/ / O C G R fig '• �[ <br /> FACIL TY ADDRESS: + N • �G�N Ie, <br /> TANK m#39-.U5 S 3 TANK SIZE: O O PREVIOUSTANK C NTMM: CnV nV <br /> *#+#«###rw+###w###wswr#tt***iii#*#ix##it}wrwwrww#t#fs#q##srWYw#rt»##s##sw+wrr*#swY##Y:rw*t##Yrtw*tai rr### <br /> SECTION 2•To be filled outby tank removal contractor: <br /> 2/� <br /> Tank Rcmoral Cont<actar: y <br /> Address: 7 Al, City: Zip: 2 <br /> Phone#:( Z09 ) .3 Z`I 7 �j Date Tank Removed: <br /> +4##r4iiwVt+ft####rt#WW#t#**!*!i!#!ii#####f##t»»w##w##iw##rlrYYrtttiii##iirYYWYwW*ii*itirt##r#*t######r ***it <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor-, Ole .JG. <br /> Address: �7 /V. J G/�/ylgrJ i2y. city: Gtv/> 1 zip.--,--'.* Z tl <br /> Phone#:( Z <br /> Authorized representative of contractor certifying through signature below that th;tank has een decontaminated in an ap roved <br /> mavner as�required by C(al EPA. DName:r/4 2 7/N //547it P�Tide:� fS)DF.� i signatureDate o 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 Namc: G i CG L <br /> Address: DD SoL)Tf/ ZLI)0 -I city: SZiqj62eU zip: SJR <br /> Phone#: 15� S <br /> Date Tank Received: 1IL31 <br /> J � <br /> Name: Tit1e: JAL/�4P-r/t. Signa Date 3/04 <br /> ##*##itf�Y'�+•^••'^��s#!#*#*#M*WWrt'##ssis*trwr#Wwt#sis#w#r#Ww#w»###ir#rs#rssrslrla*ssssiis+sr*iiw ww <br /> EH 23 046 (Revised 3/15/02) Page 10 <br />