COMPLIANCE INFO_1985-1993 - Laserfiche WebLink

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7� UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD s,•.,ss,ssssss„•s•sss••s•,ts•,•,•.,.•,•ss•.s...•••..,••.,s,s „••.,s•.,•,,.s••,stss•ss•,••,s,•,•.st•,s••.,, SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affuced with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: Pac k- jt C Fel[�— FACILITY ADDRESS: 3y5 /w 4 —(y -m Sc uw n J&► C r` t J `bj ►y n TANK ID #39 - J967-02 p ; SE'Qo � --c"I l'),St:el Z Tank Description: ss•s•sas•••s••ss•sstsssssstsats,s,•ss „ ,••ss•ssss-.•••••,•s• „ s „,s•ss,•♦ssss•ttsss,ss•••,ats,•,sssass•ss•s SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Amnion F/1Atneerii J Address: �O� l J lc d)rnt)er J:tr'e2 City: C(Qj1NCA IJ Zip: A-9 Phone #: (y i6 ) �g'' 6 0 i� Date Tank Removed: SECTION 3 - To be filled out by contractor "dQlaminating tank": Tank Decontamination Contractor:R' Enwrionm;� ,A, ( (-Wu e i Address: "-i 13 Lctk d r 1J r luC City:1��Cjrj Zip: qy �� 6 Phone #:.5( a) 222-7910 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as requW by Cfi�]EP4 Title: /U - it)o✓ -- 53 s,r•ssssssss•stssstttsstssssssstsss,•s•s•t•••s,t,s•s••s•ss•s,•stststtststssssasstssstsssss•tsstssttssssssst SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Address: Pat-ryj City: RJZip: Phone #: e 1 239— 1'9q3 Date Tank Received: Id 10 W" Signature `T`' Title:'Bz�-vis assssssssssssssssssssssssssstss•sssssssssssssssstssssse,ssstsses,ssass,•ssssssssss•sststsss•ssssssssts•s EH 23 049 (Revised 7-10-92) Pape 10