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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ss••••#t#/////###i##{iii# {{s###/#•i•i•#sir+� � <br /> St CT1ON 1 - Public Health Servica Tracking Shut will twp impany each taut affixed with its site identification num bcI. <br /> The Tracking Sheet Is to be returned to Public I-iodth Servim Idibig V dell of ameptancc of the tank by the disposm of <br /> recycling facility. The pa Wt holder is resp4usible for Muriq that this form is completed and returned. <br /> FACILITY NAME: t <br /> FACILITY ADDRESS: ZC> <br /> TANK ID #39 - �` I Tank De"ptioa;. <br /> ••+••••i•f*ii###/##/i//###//{{{ii{i/N{{#i#{{{#{i{{i{{ii{ii{i##i#/i//e/#///{#•###s♦##iii##•##•/••+•+•s�+►.. <br /> SECTION 2 - To be filled out by tank remov I coutDctor, <br /> 'Tank Removal Contractor: .l Y( -- EIL, - <br /> City::�S '�c- r A� Zip: Ste. <br /> Phone #: Date Tank Removed: <br /> +a•••••H•t###s##/i####{#{i#{i•/{{{{###iii{/{i{iii{i{•iii#{{#s{i{{ii{♦{##/s###/##/#/###•y#•••••••+•r•�u�+•.. <br /> SECTION 3 - To be filled out by tout Ctor'CIM tataiaaliag taw; <br /> Tank Decontamination Canttactor. ��� �1 �• ��--__..- _. __ <br /> Address: g20 llln C�iL1 en,+1 _ City:5 �f��l Zip:����G� _... _. <br /> Phone #. ( � `Y��'r g '5_ <br /> Authorized represe tative f co t Mor Ce l; thwup Signaturc below that the tank has been decontaminated in uu <br /> approved o r uir EPA <br /> Signature: •nue..."� cis ---.-_•. _ <br /> •••+*•••••sss#s##/#/sss##sf{{{###{i{{{{####{#{###i{{ilii/ss/#sss###/{{##i{{is#sass##s/•s#s•#••••••••#••+, ., <br /> Si.CI'ION 4 - To be signed and dated by an outhorind ropr"rtUtatire of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: - <br /> Address: Cit]" Zip: <br /> Phone #: <br /> Uate'Tank Received: -- <br /> Signature'. 'Mile: --•_. . <br /> aa+•f•##•ss#t#/t##iii#//iii#ii/{ii#»#{{##/iiiiiHiiii{iii#iii{i{i{fi{{{##//{s###i/•/s{s#••ti•••••••••�+. <br /> EH 23 049 (Revised 7-10-92) Post 10 <br />