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1 ) <br /> ' UNDERGROUND TANK [)IsI°t)sITI()N TRACKING RECORD 000190 <br /> aeea.reriiraff tlreaaas............m.ararisariessariwsrsasasa...mrsrrraseirreriaarr...r.ea*Aaa.....aseeasea <br /> SECTION I -Public Health Services Trackin,Sheet will accon►p,_iy cacti tank affixed with its site identification number. The <br /> Trxkin_Sheet is to he returned to Public liealth Scrvicc%Within 3t)davc of acceptance of die tank by die disposal or recycling <br /> facility. The permit holder is reslxin%thlc ftx enwrin,that thi.tiNin is completed and returned. <br /> FACILITY NAME: ` N- - ----- t eMnton <br /> FACILITY ADDRESS: ,S„rrit HAenow No W's ui Tr�k�► <br /> TANK IC)#39. ank ikecriptiun; wan •,ih�n ran�ity,.r]it�1e-w•dled tihrrcla..t-mk <br /> srasarsaaffasrs=r+ear=ss.aa+riisarsas«area=aaasssiriirassfsf«assasf«aflasrfsfsaaaararaaa=asraifiaasaeaesrr• <br /> SECTION21-To he tilled out y tank removal Lontractor: <br /> Tank Removal CoHitractor. <br /> Atkircea q oZ C C�Mm r [ `ST Cily: Sag ZS5_Se State: �+ Zip: 9 s is <br /> Phone #: I�0 )�l§3— nate 1•ank Renwved: _ i I ,1•y <br /> «afrersaa«ff««a««f«!«ifrrrasssrr!«s«Eases=e«sifrersmsfsfessarass«ss«srs«fr«ss«a««aea0inr+PsitBsraaraaassarasra <br /> SECTION 3-To he tailed out by contracts "decotit:uninatin,tank": <br /> Tank Decontamination Csuttrictlx: � <br /> Address: City: State: Zip: ,_--- <br /> Phone #: ( ) <br /> Aut1w ized representative of ctmractiv c-mifyin,timm._h signature below that the tank has been decontaminated in an approved <br /> manner.0 required by CaMPA. <br /> Signature: Title: <br /> SECTION 4-To he sighed and dated by an authorized representative of die treatment,stome,or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Addrems: City: Zip: <br /> Phone #: <br /> Date Tank Received: <br /> Signature: <br /> Tide: <br /> fear.slrsaraesfasssssfsssssrsfslsss«!sr«ra«srssaasrsrs«!«•«fflasrasssssss+rssssssersasss«aafs■«sfssmesfaeae <br /> EH 23 049(Revised 7/10/92) <br /> J <br /> It) <br />