Laserfiche WebLink
UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />fttlttft!••iiRRtt•t••fi•itffttRtlt#fttitftttt••tttttttttlR•tttitRiifttttRRRtttt•ittRft•tts•lf Rftitftttttttt <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: pace �i c 8 e l t!l7� �'�{ �) Tic �-1 <br />FACILITY ADDRESS: 3E N- r f o u u l n J t t(<< J `b `UtA <br />TANK ID #39 - 1!80-0) Tank Description: e�S�00o ^�QI I ), 5 t'd 4W'4 <br />RRitiistt•tttlsiitR•it••ttftttffitftlitffstttttit+!#itttttf•ttitttttfffitftitftf#ttf tiiitt Rfi•ftf ttiittft•Rt <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: A (nn �On F n a u%eer i nH ( n f <br />Address: h 8(� l xc d)rnt��S+rhe' J City: CrdpNCA`(v zip:_ <br />Phone #: Date Tank Removed: <br />..i..!••.••.•tit•••t•ttti•Rittlltt•tttfttttttffttRtffttlltttf t•..••..tftftN ••Rst••iRttlttf►•tti•..••. •.... <br />SECTION 3 - To be filled out by contractor "d taminating tank": <br />Tank Decontamination Contractor: Re Ml0 I Fn r rnn F <br />Address: "-i 3 wJ rs d r D r lUC City: Zip: <br />Phone #:5( l D )_ 2 —7810 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner as requjred by WIEP <br />Title: AL AIOy 93 <br />is•sissi#tt•ssifiitttitltliRtsitRtstt#ttfft#Rttf•ttitttttttit/Rttit••tRR•iRt•f!!•ftttsRttt•it••tt•l Riiisitt <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 />Facility Name: <br />Address: <br />P <br />City: <br />Zip: 1 qw I <br />Phone #: <br />Date Tank Received: i i ((o 193 <br />Signature: D4'ZF:�T 5A. To Title: <br />ssssssssssesssstsssssss••s•sssssRssssesass•ssstsssssstssssstsss••stt•fstssittss••tt•sslRRisssssssiRsssss <br />EH 23 049 (Revised 7-10-92) Page 10 <br />