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VICEAL Th <br />93 DEC <br />UNDERGROUND STORAGE TANK DISPOSTTTON TRACKING RECORD <br />SECTION I - Public Health Services Tracking Sheet WM Accompany <br />The Tracking Sheet is to be returned to PubUc Health Services each malt affixed <br />with Its site Identi(i�uoa number. <br />�1°g fatty. The permlt holder is res 3ithi°- 30 dem of aooeptaaa of the tank 6 <br />.� �poaslble for easdrg that thJs form Is completed and returned, Y �c del or <br />FACILJ7y NAME Yt I pO 4 (. 3 <br />FACILCT y ADDRESS: 1 <br />TANK ID #39. <br />'Tank I%tscrlption; <br />"'no N 2 • To be filed outbytank r rrr..•.r..,,..rr•,.r.rr,. <br />Tank Removal Contramn. 1L� /_Ceti contteaor ••••.,.•.•,.. <br />Address: 6 G? <br />Phone r:03r-I City ZIP: 3��8 <br />Date Tank Removed: t l <br />...,••..,....•................••...............•.,.....••,....,...........•.,....•...•..•,..,.............. <br />SECTION 3 - To be filled out by contracio�"d <br />Tank �a�na�B tank <br />�nww"1lon Contr.rrn. <br />Phone #: <br />3153 A-�� q <br />City, zip:'3X38 <br />Authorized repreaeatatk of contractor cer(ify(n6 through signature below that We tank <br />aPP�d Mutter as required by C41 EPA has been dcconfeMI ated in an <br />S1rC17gN 4 .TO be signed-------'_ <br />an <br />acoePtIngg tank and/or pipin author(mi g. representative of the treatment, storage, or d sprual•fac;Uty ••••••r <br />Facility Nama: - +` i1� IrO 1 l A s f _r_ <br />Phone #: <br />Date Tank R4f4d, ( L; 5 — <br />EN 23 069 (aavlaad 7-10.921 <br />Page 10 <br />City: M � Z* q 3 bad <br />