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r <br />r <br />UNDERGROUND STORAGETANIC 1WWOSITION 'TRACKING RECORD <br />tttttltttttitttttttttttttrtttttrrrrrlrrtrr0rrtr•rtttrrrrrrtrr00*$*trrrr♦tttt t rt rttttt*r r t t♦r*t••tr t rr J►rttt <br />SECTION 1 - Public Health Servicers 'Tracking Sheet will accompany each tank affixed with Its site Identification nurl.ber. <br />The Tracking 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 penult holder is responsible for ensuring that this form Is completed and returned. <br />FACILITY NAME: 4-'7. fAtX <br />FACILITY ADDRESS: A7af—1 <br />TANK ID #39- 1 tv(0 ' 'Tank Description: <br />tttttttttttttrttrrrrrrrrrrrrrrr♦r«r♦rrrrrrrrrrrrrrrrr«rrrrrrrrrr«rrrrrrrrrree•see♦«ee•eea«•ee•se«erra•e•e• <br />SECTION 2 - To be filled out gy tank removal contractor: <br />Tank Removal Contractor: <br />Address: z--'/) Z ,r d% liet.j ��`>� City: . :�i'Za1(i Zip: <br />I hone fit: `y'e2 �,S „� � Uatc 'Tank Removed: <br />00 r r 0 t rtttr r ttttrt•tttt r r r0 r 00rr0r04r00r000 r 60«r00rr0rrrrrr0r4r r r r 0 r r« r r r r r r r r r r r r r r 0 r r r r r r r«e«erre. .0er0r <br />SECTION 3 - To be filled out by contractor "decontami�ting tank": �- <br />Tank DecontaminationConttractor:,�77-0<.� k-t`"c.�'� <br />address: g2� 900 G -11'` -IC r _City 3-rL`•C "i'Gt� Zfp: <br />v <br />Phone #: <br />Authorized represell <br />approved manpjj as <br />Signature: <br />r certifying through signature below that the tank has been decontaminated is an <br />� k_z�- ,�! �'� ('•'-c '�� Title: ,Y,S <br />rrrrrrtartrttttttttttttttrrrrrrrtrrrr«rrrr«rrrrrr►rrvrrrr«rrrrr►rrr►rrrrrrrrrrrrrrtrrrrrrrrrrrrrrrr«.«rrrrr <br />SECTION 4 - To be signed and dated by an authorized represcnt((ttve of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: City.' �(.Y�-[-U� 1=— Zip. <br />9 <br />Phone YI: <br />Date Tank Received: <br />Signature: <br />h0c: <br />. 0• 0 0 0 0• r 0 4 r 0 0 r r r r r r 4 r 0 4 r 0 r 0. 0 0• 0 0 0 0 0 0 4 0. 0 0 1 0 0 4 0 0 0. 0 0 0 0 0 1 0 4 1 0 0. 0. 0 0 .. 0 0 4 0 0 4 0 0 0 0 0 0 0 e e 4 0 0 0 0 e 0 4 0 r r 0 4 0.! r r r <br />1 23 049 (Revised 7-10-92) flnlun i(I <br />0 <br />