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UNDERGROUND STORAGI, "TANK DISPOSITION "TRACKING RECORD <br />tit0tflfttfa00000•♦000000♦#f#t##t#*000000*!#r0!•tt••ftt•f0tt0trlfttirrtifttt♦!tl t0tf0tt**!!lfttf tt tti rf0ttf <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with Its site Identification number. <br />The Trucking Sheet is to be returned to Public I Iealth 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: � le -1 � � <br />TANK ID #39 - 'Tank Description:,(.Z',�)�� <br />rlttftitttttttft#rttttfiffft**tff*rf*artattvtrrftrvvr+v.+tvvvtt►rrvrvrrvtrvvvi'iti�i'f• �t✓ri ♦vv� t�"a�fi �� <br />SECTION 2 - To be filled out_by y tank removal contractor: <br />"Tank Removal Contractor. <br />Address:��Z"O d� r �/�LlG>L1"� City::�*'�)t( Zip: <br />Phone #: ( zCxb 4W r'0�� Date Tank Removed: <br />•0000•f*t**t*t•ft#►***/tt0tt*****0*t*r*t!*tf*0tt*0f*0*0**0fIII, r**$**!f*#0****** f f* 0 t f* 0! r! a** i* r** f** a b+t ttft <br />SECTION 3 - To be filled out by contractor "dec:ontamipting tank": <br />Tank Decontamination Contractor:�Gt`p►_(� �E �lC r� , t�t�i��t�� <br />ddress: OZ -0 go- G -t 1't1s _City-TZCtlZip: <br />Phone #: (T. -M)' <br />Authorized represe tractor certifying through signature below that the tank has been decontaminated in an <br />approved manpr as Re r bjr Cal Y�. <br />Signature: 1��- Vic Title: ?r✓}t!,� <br />titval+i!**titttff*tlftttfti***tivttr!*rrv*rrrtrt+vrlrrrraiva+•arrrra*ra*ttrvr**rrlaatt!!*lrartrltlaartlt#• <br />SECI'ION 4 - <br />Facility Name: <br />To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Address: J r' ��ij/� %r _ City: C C— Zip:S S�I <br />Phone #: ( ) b —q- '7 P <br />Date 'Tank Received: <br />Signature: <br />Title: <br />+*******00**0t*4*00**0***0*t#****/ftf!**!*********tfi****0********!*rr*f* t f!** i* t f*! r**** t**** f t 0 f* r„!!f <br />'I 23 049 (Revised 7-10-92) Pope 10 <br />