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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />}sst}ttt}t}***sift* tt s t s s s sf ftotsstttottsosttstsst}s stssstst ssototfsst}ttittst} f t t} f t s f s t t t s s t f f t f s s f} i s of <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank aff-med 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: IPA( -�C C E e I I (U � O q, J) <br />FACILITY ADDRESS: syE !w ou uln Jtrel t J `cam `�11 <br />TANK ID #39 - Tank Description: �S� (QI Ion _Ste el �4n� <br />}ftstft}tttftt s t}t}ffftft}ssttf s tssttttt}ftsst•T■sosfss s s ttttssttstotttttttttstsit•}ts}tsttttt}ttttttt <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:Aronion FneAmeerir <br />Address: J lc 6MLcr S�(t�� City: CrQ��n lc7 Zip: <br />Phone #: (yi6) 3gI– 16 D U Date Tank Removed: 1 16&-s <br />t ttt..to}coot}o sstottt s}sootstsf s tss000tss ttsttt tstss tss*sotsss tss}tsstt•.............. }................ <br />SECTION 3 - To be filled out by contractor 'd taminatin tank": <br />Tank Decontamination Contractor:d��e ( Enut on.n &rutce I <br />Address:fd e— D rlu( City: RArOONJ Zip:- <br />Phone <br />ip:-Phone #:.S( 10 ) 222 —7910 <br />Authorized representative of contract;Poiyingr It signature below that the tank has been decontaminated in an <br />approved manner as required .by Cal <br />Signature:_ <br />Title: %D /t/oJ 9_3 <br />•tstssssstssst}sstssssfsstss}ss}ssssstts}sssssssssss••ttfsffstttt}sssfsfst}sss}tssfatsssssssssssss}sssssatf <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 />E7,Facility Name: l` c) <br />Address: ass Parr ';a1UJ City: Zip: 1W I <br />Phone #: ( SIS) 2-:�9-13g3 <br />Date Tank Received: <br />Signature: -rATitle: -g�A.,W <br />ssets}ssssssstssssssssssst}ssssssssttessssstsfstsstsssftssfs}sfsstsstsssss}}ssssftsssstsssssssssssstsss <br />EH 23 049 (Revised 7-10-92) Paye 10 <br />