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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> **##**#*****##**#*************#*****#*******#**#***#********#**##**********************************##***#** <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 Health 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: 3y'U5' Y ]► y'(� �.�-' ►�� , G1 ,�S�ZlJ✓�' <br /> TANK ID #39 - Tank Description: <br /> sss*s***********#**s#sssss*s**s**ss**ss#sss*ss#*s*sss#s*ss*#*s**#*#*******#****##*s*s#s#*s**s*ss#*ss##***** <br /> SECTION 2 - To be filled out byaontractor: / <br /> Tank Removal Contractor: /�2K�pn1 �iY 144,,: <br /> Address: Zy_ND. Ij /-j1014 City: Zip: <br /> Phone #: Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating4oftw: <br /> Tank Decontamination Contractor:_ e k-<DR) <br /> Address: 4e 1 12lu City: -ehek—T-o1. Zip: 7Pa"��AGJf e <br /> Phone #: (ZDrl,) y�v ri3 3"Z <br /> Authorized represe ative o contractor-Certi"g through signature below that the tank has been decontaminated An an <br /> approved ma ner a uire PA- <br /> Signature: <br /> ASignature• -- Title: <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or pipin <br /> Facility Name: <br /> Address: y <br /> City: Zip: <br /> Phone #: ( <br /> Date Tank Received: <br /> Signature: Title: <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />