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SEMON I - Public Health Services Tracking Sheet will &=inpanyaffixed with Its site Identificationnumber. <br />'Tracking Sheet to be r 1 ':3Public;VServiceswithin I days of a=ptanceofthe tankbythedisposal s <br />recycling facility. 1pennU1: t is responsiblefor form is ♦ t:1 and returned. <br />♦. filled out,bytank removalcontractor. <br />Tank Removal <br /># ♦ + a072, VJ % <br />1 <br />!a <br />i <br />.,# C` Removed: <br />To be filled out 1 contractorOdecontaminating 1 <br />Tank Decontamination #r Eslr'1 <br />i * <br />Phone r <br />V -1257T7 <br />'♦ i 1 i #: / h {: ;• � I 1 ♦ V :, i i Y# t :" i I is <br />Signature: Title: <br />SECTION 4 - To be signed and dated by an authorimad repnisentative of the treatment, storage, or disposal facility <br />accepting + and/orpiping. <br />Facility Name:--- GI-rAAjie— <br />Address:Zip- <br />Phonei + <br />Signature: Title: <br />ssssNOassssOsaassssssssssssasssttsstes#♦iMtOt•ilkfl®tt10i®slif stlNYas>•®ilOit+Y OO/1or Ort•!ttl Ni►®®f t)titif sll <br />ER 23 044 Revised 7-10-42) Poo& 10 <br />L'd 901OLLZ6OZ 8V1S1S3M/dV1S-nV WOdA WVZL=6 866L -6Z -v <br />i <br />FACnZrY ADDRESS: <br />K <br />• <br />♦. filled out,bytank removalcontractor. <br />Tank Removal <br /># ♦ + a072, VJ % <br />1 <br />!a <br />i <br />.,# C` Removed: <br />To be filled out 1 contractorOdecontaminating 1 <br />Tank Decontamination #r Eslr'1 <br />i * <br />Phone r <br />V -1257T7 <br />'♦ i 1 i #: / h {: ;• � I 1 ♦ V :, i i Y# t :" i I is <br />Signature: Title: <br />SECTION 4 - To be signed and dated by an authorimad repnisentative of the treatment, storage, or disposal facility <br />accepting + and/orpiping. <br />Facility Name:--- GI-rAAjie— <br />Address:Zip- <br />Phonei + <br />Signature: Title: <br />ssssNOassssOsaassssssssssssasssttsstes#♦iMtOt•ilkfl®tt10i®slif stlNYas>•®ilOit+Y OO/1or Ort•!ttl Ni►®®f t)titif sll <br />ER 23 044 Revised 7-10-42) Poo& 10 <br />L'd 901OLLZ6OZ 8V1S1S3M/dV1S-nV WOdA WVZL=6 866L -6Z -v <br />