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NV.. - <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />rr s♦*ta*i*at*ata*a**rapgragtr*ra•tat**t•*ti ry at.tat*rr*ra*t*•rr*r•*****raart**tr*era**atit **r*,****tt*** <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank afl-txed 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 holder is responsible for ensuring that this form is comnleten e..n ....,. ea <br />FACILITY <br />FACILITY <br />TANK ID #3Y -Lim( , <br />/=0, f Tank Description: <br />...r.♦.r *•r*asr*.,uta,*.tit.rr.•r....i.•ri.r•.•...•r....t..r.,r*..i..T..•a.i.,...r...•.rri.....r.. <br />SECTION 2 - To be filled ouE try tank removal contractor: •...... <br />Tank Removal Contractor. IC <br />Address: <br />Phone <br />aty: ILu r- (Z f Zip: ClS\n� i <br />#: %� —7Ljy� a b3 <br />� Date Tank Removed:—'7 l g <br />.................................................................................. <br />SECTION 3 - To be filled out by conirgor'decontaminating tank': •. <br />Tank Decontamination Contractor il �_c. , <br />Add <br />Phone #: <br />City: Zip: <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner required by Citi EPA <br />Signa <br />Title:-/, aec, 4"iLLC, — —, <br />..............rtr...*,..at..i**•i...............•....r................i............................... <br />SECTION 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:_�o <br />Phone #: <br />Date Tank <br />Signature: `- <br />Title: <br />****trait tttitttaitttitt taattttrr tttttt ttta.tit.tttt•t.tttatttr.t.tt..tttttt. tittttt tai t.ttttit.ti tr.it <br />EH 23 049 (Revised 7-10-92) <br />Page 10 <br />