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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Tracldng 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 days of acceptance of the tank by the disposal or <br /> recycling facility. The permit <br /> holder is responsible for ensuring that this form is completed and returned. <br /> FACII.I i`: NAS ( . /E/) 02n 7'1 S,r j <br /> FAC.L.= ADDRESS: 5 <br /> TAVK ID X39 - �® Tank Description: <br /> SECTION S - To be filled out by M retgoval contra¢grr <br /> Tank Removal Contractor. �/CYC r lL [(J / �1 <br /> Address: �o C X C1W /l�� City U/Jr°ip!lZO�o Zip: <br /> Phone +: (�l(J 1 �4� 7 0� Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> .ank Decontamination Contractor. <br /> Address: irr Zip: <br /> Phone : <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by C31 BPA. <br /> Signature: Title: <br /> ........................................................................................................... <br /> SECTION 3 - 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:��� LC <br /> -C <br /> address: R CitykXA021 zip: 9 yd'0 <br /> Phone =: ! S/O ) oZ -3 S — 4-�3 9 <br /> Dace lank Received: <br /> Signature: ittle: <br /> ........................................................................................................ <br /> 53 119 :Reviser! 7-10--Z; -age '0 <br />