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:r <br /> SAWN JOAQ' COUN Y PUBLIC HEA T3 SERVICES <br /> E.Y )NMENTAL HEALTH DIVISION <br /> UNDERGROUND S _GE TAN DISPOSITION TRACKING RECORD <br /> - WW##}WxMW+Y+k}W}}M#W#}W}fi WMW WxWWxw Wx Wx Wiz -};M##MWz##WZWMW WzxW+kWx}WWWWWMW W}MxiW W}}}z}Wfix}x}#}#WW###}M}W}M} <br /> SECTION 1 - Public Health Services Environ:- Heath Division Tank Tracking Sheet shall accompany each tank affixed with <br /> ;is site identification number- The Tank Track._ __et is to be returned to Public Heath Services Environmental Health Division <br /> within30 days of acceptance of the tank by the csa or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: 6�u-,CQ-- �t <br /> FACILITY ADDRESS: 17-0-00 S&, <br /> TANK ID #39 - TAi\'K SIZE PREVIOUS TANK CONTENTS: URL( -� <br /> W#WW#MMMMMM}W}#}}#}#WMWWW}W}}WW#WWMWW#+. nwWfi}p#Wn##WWWW#xWWWxW W#MWrt WxxxfixWZW}zW}#WW}Wxx}}}aWW#W}Wxx#xWx} <br /> SECTION 2 - To be filled out by tank removz. .:tractor: <br /> Tank Removal Contractor;,�o ,S—co <br /> Address: 5n Zip: gfs-Zmg- <br /> Phone ;i: (.Zct ale Tank Removed: <br /> WMW##WWW#M#%k#W+Fh W#xW}WW#W}W#WW#WM##WWWti �WWWWZWWxWW W#x#xWxxWvz#x#-Hx#x:R4#xWW}##zW WW WxzzW W}W}}{e#WWW}xWxvvx <br /> SECTION 3 - To be filled out by contractor " aaminating tank": <br /> Tank Decontamination <br /> rl Contractor: cx <br /> .. ; S�2yrct_ -rst�7 } ,E,E�. CID•.�[„�Ic <br /> Address: 6<? /Qo, W A3to.y S Ciy -r�T-zCP--Tm-k,� Zip: l/S�US� <br /> Phone ,H: (&-zz_) &of <br /> Authorized representative of contractor certifyi: -_ough signature below that the tan};has been decontaminated in an approved <br /> manner as required by Call EPA. <br /> Name: Title:_ Signature: Date <br /> ##MMW#WWWW}WWW#M+Y}#WW##WWWW#MM,#WW}W WM#W:. nWW4}fi#iWfiW#Wfi+4MFW}MMW}#M}MW}WMZW#WWWMVMM}y,#WWWW#WW}W WW WxWW}}WWW <br /> - SECTION 4 -To be signed and dated by an ai, ized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: cf,4t,— <br /> Address: 706 _A-11 City: Zip: <br /> Phone N: (?-loq <br /> Date Tank Received: <br /> Name: Title:_. Signature: Date <br /> WMWWWWMMWxW x#WWWW#WW#x}#W}W}W MW'v WAvW#x Wn... _uaMWWMWW W}}W:kW Wxfi}}xxWWW}WWW}WMW WWW#Ww#}T.W WW W}WWWWWW##W}}#WWWM <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />