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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RI3COID <br />lYYYYtYilt•YY••��t••�Y1YYYtYlYYYlYYtYYYYlYlYYYYYYY•YYYttlYYYYlY♦tslYtlYYYYlYf Yt►YYYYYYY YYYYYYY YYtYlYY •YYlYY <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site Identification number. <br />'17te Tracking Sheet is to be returned to Public I iealth Services within 30 days of acceptance of the tank by the dispesal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME:Z41 7 <br />fi%il('�/'�,-j/�1 j -- ---- <br />FACILITY ADDRESS: M-) KA <br />TANK ID #39 - ��� ' Tank Description: <br />Y Y 0 Y Y Y Y! Y Y Y 0* 0 0 1 Y*• Y Y Y Y Y Y Y Y Y Y Y Y Y!! Y Y Y Y Y Y! Y Y! Y Y Y Y! Y 0 0 0 Y Y ... 0. 0 0 .. O O Y Y Y Y! Y Y 0 0 0 0 0 0 0 Y Y 0! O Y Y Y! 0 0 0 0. 0 0 0 0 0 0 0 0 0 0 0 <br />SECTION 2 - To be filled outPy tank removal contractor: <br />'rank Removal Contractor:) / � V'd c _ <br />Address: 2.o & r j�lU%1 ��"r City:h 'r-54 Zip: <br />Phone #: ( ) ,s ; Date Tank Removed:__ - <br />YY1YY•*r/1YY�����iY���l►i��lY♦YtYYYYYlYYYYYYlYYYYYYYYYYYt YYYYYY Y+OY41404YOP10OYY 04YOY 0000.00 Moi OOOY000'0l YO!• <br />SECTION 3 - To be filled out by contractor "decontamipting tank": <br />Tank Decontaminationr Conttr�actor:,:disc <br />.ddress: g2.d � G --I tt1Cd City <>-Mz'�q� ttlfz <br />Phone #: O —� - - <br />Authorized represe tractor certifying through signature below that the tank has been decontaminated In an <br />approved mane r as ke- 'r b_CaI Py. <br />Signature:U �--' i�k`� �`\?c .c Title: ,5 <br />.00101!lYYY�YYYYYYYYYYYYYYYlYYYlYY101Y01lYl1 YYOYYYY YYIOYYYiYlYY♦!O!0!!Yl YYYYYYYtYYl YY!lYYYYYYYYY YYYF='OYYYY! <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 />t c" <br />Facility Name: <br />Address: J ! ��V�� �_ ';� City:: I LIIG��,� Zip: <br />Date Tank Received: <br />Sienalurc: "i'itic: <br />..... 0 ... 0 0 0 0 0 0 0 0! 0! Y Y!!! O Y 0 0 0♦ 0 0 0 O O O F 0 0 0. 0 0 0 .. 0 0 0 0 0 0 .. 0 .. C 4 0 0 ... . '1 1 1.. 0 0 0 0 0 .. 0. 0 0 0 0 0 0 0. 0 0 0 0 0 0 0 0 0 Y Y 0 ! Y 0 <br />1 23 049 (Revised 7-10-92) Plig'. 'i!? <br />