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8-21-1997 3: 18PM FROM ALLSTAR/WESTSTAR 2092770106 P. 2 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - Public Hiss"Services Tracking Sheet will accompany each tank 9M=d with its site Identification number. <br /> The Tractdng Sheet IS to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br /> recycling faclllty. The permitholder Is res m <br /> responsible for eoting,that <br /> ttthis form Is completed and returned. <br /> FACILITY NAW-J itc6 <br /> FACILITY ADDRESS: W (/i -}r A rIq D n e <br /> TANK ID #39---UK Tank Description: <br /> SEC17ON 2-To be Sited ou b contra�Wr. <br /> Tank 7ON 2. oo e filled <br /> P�� (]t r C X111Iran r'► e 1 fA( - v)� <br /> Address;_20/ /i'/(.li/]�'.effy ( )fi(�P City: v Q� Zip; <br /> Phone#: 209 ) (07,S- 93 J g Date Tank Removed: 17-11-C <br /> ..••..••.•.•t•....•••••.•••.u•••....•••.•.......•..• <br /> .......... <br /> SECTION <br /> SECTION 3-To be tilled out by watrador•q iminati g taolc•; <br /> Tank Decontamination Contractor: <br /> Address: OI i� 1! d i Je city Gi ezo/ Zip: G13(o37 <br /> Phone #: <br /> Authorized resentativc of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved r as required by Cat EPA <br /> Stlptat 11tle:�r�4 r r7P�Lf <br /> 0000••... <br /> ......•f••tt•...p.•N I•.•H•tt••N•NN•ltl.q tl.••H•♦•,••i.•N••a H t HH,••l HHNti••HH.• <br /> SECTION 4-To be signed and dated by an authorized represeotative of the treatment,storage, or disposal facility <br /> tank and/or Piping- <br /> Facility <br /> Facility Name- /7i°ln�7 )) eo <br /> Address: ,p ( {U City_ K16ato Zip- 9277.33 <br /> Phone #: <br /> Date Tank Received: <br /> Signature: Title: <br /> Ea 23 049 (s•vlsed 7-10-92) vtae 10 <br />