REMOVAL_1992 - Laserfiche WebLink

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UNDERGROUND TANK DISPOSITION TRACKING RECORD ........................................1....ll.......«........................0.4.60................ ..... SECTION 1 - Public Health Services Tracking Sheol will accompany each tank affixed with Its site Identification number. The Tracking Sheet Is to be returned to Public Health Services wlihht 30 dues of acceptance of the tank by the disposal or recycling facility. The permit holder Is responsible for ensuring that this form Is completed and returned. FACILITY NAME: AL 4 AA-el FACILITY ADDRESS: Z Ca 3 6 TANK ID #39 • _. .16 5- 0�^Tank Description: d 6 0111—\J H..I H....N..V00601«00000.0....0..4.4...0...............!!.400.!0000.000H...0-..................... •.44 SECTION 2 - To be filled out by ank rc ovalcontractor: Tank Removal Contractor: (� p Address: J1 _ �- IL-ol City: Zip: U Phone #: ( ()1 l�� f f f (Q' Date Tank Rernoved; ...«....«....«•«.«.......•............................................0000........................... ..... SECTION 3 - to be filled out by contractor 'decontaminating tank': Tank Decontamination Contractor: Address: -- City: ZIP: Phone Authorized representative of contractor certified by signing below that the tank has been decontaminated In an approved manner as required by the State Department of Health Services. Signature: Title:------ ...................................I.......... itle:...•...............................6.......... SECRON 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: M Address: ��5 a r ( 2 ti�(fj . l �PS� City: Zip: Phone #: ( Date Tank Received: Signature: Title: .......................................................................................................... Page 10 EH 23 049 (Rev 2/9/91) wp