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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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- Ty - G r r y D c TfAI y <br />FACILITY ADDRESS: G$ EAST �L�d..y�y STiQtCT i/2ACs/ G4 �7J37� <br />TANK ID#39-� Tank Desciptionhh'/ ��7'� illus f1 1 <br />..............................................................::...................:..........,............ <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank RemovalContractnc r.rnr...r _ <br />Address: /461 N r, . i rEy t/ W,} <br />City:JL/ _ Zip: rfr37! <br />Phone Date Tank Removed: <br />SECTION 3 - To be filled out by contractor 'decontaminating tank': <br />:Tank Decontamination . Contractor. W (t C(t Fi f GA) V LRDAJ f 1 r <br />.0 �A Z S F,eui�ES <br />.ddress: /4t/'Nric'VZ <br />Sone <br />City: LI?A G �_ Zip: —Jn LEI -716' <br />)rized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />ved mannegas Mquireddpy Cal El� A <br />-: vlguature: /� / <br />Title:_/'fit 3i c{ <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal fatality <br />accepting tank and/or piping. <br />Facility Name: T -1—Z b(t o <br />- �C.e4ME JLQ <br />Address:-3SZ2 CT^O� iQJi� <br />City:_S9[C�/yFiV, Zip: S,? Z-7 <br />Phone#:f�i/� t Lr�1_ roan <br />Date <br />Signa <br />............................................... *......................... I.,....... 0................... <br />'4 23 049 (Revised 7-10-92) <br />Pape 10 <br />