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OST COAST EQUIP SALES 1 09 668 9382 P. 01 <br /> .. . ,,. . � . . .. .. . _ _... _. ',I,i2AWwih,•. ii7t •. .;'Irk <br /> NOV 0 8 1993 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> VNDERGRO UND lrT0RA()2t'l'ANK U191109171rION ITLACK)NG' RECORt) <br /> ��••�•••••u••••••v•1••vvv•N•••rv•••r.••••.aN••••••••••Hv••r•vv••••••••••••.•H•••v v••HHN•••••1••••v• <br /> 6�C"t'!oN 1 - public Health Borvlces'Cracking Sheet will accompany each tank affixed with Its slte Identification number. <br /> Tito Tracking Shoot Is to bo returned 10 public Health Servlool wtlldn oars of 00eeptan0c of lho lank by the dlaposal or <br /> locycling fWllty. The porghll holder it respoluible for eludlldg that this form Is completed and telurnod. <br /> ACILITY <br /> FACILITY <br /> TANK ID #39 ^ _ _Tank Descrlptlom� <br /> shcr;QN 2 ^ To be 111104 out by link tomo a1 o0ntreclorl <br /> Tank Removal contractor <br /> Addtci4: $2G /a /,1lraocl �4—� City: rr . . Cpl 9 d <br /> phone lY: ((�� �I' �Dale'Itink Removod: <br /> .••••..v••HH•••NH•N+••H••••N•N•••••►••••u••NN•••••Mv••v•HN•••••••••••••.•••••••••••••••.••••� <br /> W"FlON 3 . 11b bo plied out by COMINCIOr •dwo (60011ing lank": <br /> Tank Doconlaminhllon Contrecto <br /> Address: N12.1 / <br /> d2 • <br /> phono Of ( 1 <br /> Aulhorlaed repre"ntellvo of conlitorp�rflryfng through signature below that fico lank bas been doconlamloalod In an <br /> approved mannor as requlrW by <br /> Title: <br /> Slgnaluro: <br /> n••NNVN••v•••r••NN•N•�•gnu•Nr•••d•N•rN•••••••••Ha••r••N•••••••••v•••••v•aA••1•NHN•N•H• <br /> gpCT1ON 4 • Too " 51ignd nndlcd by aulborisd tIproonlat(vo of the lroalmenl, $longe, or dbpoml fldpty <br /> P gtand <br /> ` PPg <br /> Facility Nexne:��/ / fl_ GY4 �rU((f/s '.vGl�l y <br /> Adit%,." �A� ' ' �� Clly:ALL C/�' - ZIP: <br /> phone : Zo 6 4, 8Z <br /> Thiol e <br /> Slgnature:�^ ,_� v <br /> �.�•••�••••••u•r♦:••N•N•••auu•••••••••••••1i:•v•vu•v•vu N1••••u:i••••H•.•••••.••••••HL1•••v H•• <br /> ra 21 049 (awl••d 7.10.92) P•a• 10 <br />