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V <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ttrrrttt♦rtsatttttttrtutrgr+tt+tttttr•trot.•tarn•rrttatt•.••utt•art•utr+ttrttrtwtttrt+ttttttt+t•rt <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site Identification number. <br /> The Tracking Sheet is to be returned to Public Health Services within 30 darn of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for easdring that this form is completed and returned. <br /> FACILITY NAME: TNC CL �F TQAC <br /> FACILITY ADDRESS: /O WEST fikAIV U LiUC A°A I72.-4t <br /> TANK ID #39 . 1262-- D j Tank Description: l!) ��U t� 1)S7-,A4 <br /> tq Ott•trot.•tt•ttrttttwtt••t•wt••t••+•tt••HtP•♦t.•.s•.t+as••••.•M•t••tq+•t+t+••ttt7ttt t+t-•tt•tt+•t•• <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor. WILL(i�r 6b 6AW E UM SFvZi(l�r �� <br /> Address: l u l I�ZLC UZFw/ lt//F�/ City. Wix Zip: F53 79 <br /> Phone #: ( 7n4 ) 'LL 0> S FI Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Contractor: LL&- b t/T rN (LZd�iJ/�1 c�i/TAC SF.2uIGF S Zn/<— <br /> Address: lSG/ ALL/ �11EGt� .1A1 74 City Tea�� Zip: 9S'37/, <br /> Phone #: 1 rA - Q 7.S 15 <br /> Authorized representative of contractor ' g through signature below that the tank has�j�T ta� E� <br /> in an <br /> approved manner as req ' by <br /> Signature: �fitM �" Title: /o/2Rf � <br /> ttwtlHttNtrtttttuwtrwttlstttt•+t• •ts+•t•its•tltttttrtt•+tt++t•ututstat++tltttttttl•Nttttttttttrtrt•t <br /> SELMON 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: I R.Cs4AJ (r/-/- DF SACOAMLEW76 <br /> Address: 35z6- Sz 2 q A uF City: 94RA1-4FA/T6 Zip: 9 fI7_ <br /> Phone #: ( y 16 , `I Z 1120 <br /> Date Tank Rece'wo: - (7-3 <br /> (� Q <br /> Signat Title: C 1'(1j f</4 <br /> �r ttttattttttttt•isattitt+Uttt••tt•tt+•tttHttttstt•••u•scar•t•t•••ti•if..•sasltt+t+trttttttt••at•NY+ <br /> EH 23 049 (Revised 7-10-92) Paye 10 <br />