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UNDERGROUND STORAGE. TANK DISi'OSITION TRACKING Ri:CORI) <br />tttlltitliilitlliliiitiiittitlttitlll!!llilt••/litttitiiiYt•iY itliYlYli111tii1tliitti ltttittittttltt♦+Oitil <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 I Iealth Services within 30 (IM of acceptance of the tank by the dispesal or <br />recycling faculty. The permit holder is responsible for ensuring that this form is completed And returned. <br />FACILITY NAME:i_4-rv-f�` j--- --- -- <br />FACILITY ADDRESS: �41�� rt� <br />TANK ID #39 - 'tank Description:���, <br />Y!•ttti ltttlttt/1l •1 i111//1/iYYYt/t11YY1liiii!!Y•!Y4►YYlYYi!!t♦!PYlP!!!i1♦♦•!Yi!!liY1i1li Yl1l/►IYYYYC.4PI i1• <br />SECTION 2 - To be filled out�tank remova`c:ontractor: cy <br />'Tank Removal Contractor: ��f LY , t'?`1�et- >1 �4 �c:-�• j=_("4_ ��,��� <br />Address:SZ,O f C L-L4b2i! zip: 1a' 00 <br />Phone #: (j�) �Lkl- -� 3y;3 3 Date "Tank Removed: <br />•1•lltlttlliilil tittitttlitlttitt/11iti1Ytii111itilli•••lilt11t1/►Itilttitii►fitiiitiltPtt1/ti/tt tiP Pi1tt <br />SECTION 3 - To be filled out by contractor "dec:ontami�ting tank".- <br />Tank <br />ank":Tank Decontaminati`onr Conitr�actor:�G6 <br />G--! <br />Adress: (�E'� (4/e'►i - City:`3-12"C' t� Zip: <br />Phone #: <br />Authorized represe tractor certifying through signature below that the tank has been decontaminated it an <br />approved manpjj as�(Kr b I FA <br />Signature: U �'--� T�i�-.(rc' t` Ti <br />tItlititit►i li�litilti•ilii/ttti/ll4Ytil YPl li ll ♦••tilYYY4l�4l IYIP l4/YIll11l1tl/illlilltllti tlttl•/1/+, rtl/tl <br />SEC PION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: J pj/j �_ , -- Cily G -� IJP 1.'=— "Lip: -fs <br />Phone <br />Date 'Tank Received: <br />Signature <br />"Title: <br />. 0 4 4 4 4 0 P 0 0 4! 4 P 0 Y 4 4 Y ! 4 t/ 4 4 4 0 P 0 0 4 4 4 4 4 4. 4 4 4. 4 4.. r 4 0 4 4 4. 4 0. v 4 4 4 r v.. 4. . J 4 4. 0 4 4 4 4 0 4 4 4 4 0 0 4/ 0 0 0 0 4 4 4 4 4 4 4 4 l 1 Y 1 1 1 <br />'t 23 049 (Revi8(-d 7-10-1,12) 10 <br />