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4 <br /> i <br /> I <br /> UNDLROROUNU STORAGE TANK DISPOSITION TRACKING RICO <br /> rtkt#**#/k!!#loft##!#lsttt too tot k00#6f#ft#too*/t0006666s•••t##o66ttM###�sstrr##tkksst00###k#!fY <br /> 81Wn0N i - Public Health 5ervtces Tracking Sheet will acOOMPay.eaclt tank titftxed with Its site IdentiticatIon number, <br /> r <br /> no Tmcking Sheet is to be returned to Public i-Icalth Services 101149 34 d-Ayv of acceptances of the tank by the disposal or <br /> r0g011119 fadilty. The permlt holder is tesponsible for ensuring th&(( this forth is compio(dd and returned, <br /> FACILITY NAME; 7 +� j°• J /," GO <br /> rFACILITY ADDRESS: <br /> TANK ID 039 - �a �" Tank Dcscriptlonl�y C�.�(. �1�/r�La �Vo(f. -6*xL <br /> R###kkk#r##+###k!*sro4#MiRl4t�rfk4k#t•s•rat �M <br /> t#0r4s6trttht#t••ss••#f#fR•*#t6tt6sslittf#6ksott#tt#0#6k6rt•##sta <br /> SUMON 2 - To be Riicd out oy sank removal contractor; <br /> r' Tank Removal Gontrector: "k' <br /> �. City.Y .,5�1 ZIP,_ . <br /> 1 Phone - <br /> � Date Tank Removed: <br /> •.if#####�!�#*y!#41 kt111lkk4#.til*4tkitArt.r6*t#66k•##rY#0tt6r666�ri0fof#4460#is##wkk••�►#�#kk6ks*tt00tt4Sk••e <br /> SEMON 3 -To be S11e4 out by contractor "d=ntarninating tante": <br /> `Dank Decdntaminadon Coll tractor;.,.._._._.�� <br /> rAddress• �.m 'r- - — .... <br /> Phone <br /> 01) <br /> rAuthorized represeataltivc of contractor ccrt[[yictg tltrou 1i si ttaturc belowthat <br /> approved manner 04 r b Col EPA, g & t hal lite tank has been &contaminated fit ao <br /> rsfgn,alu C;_,� <br /> its ftlt#to$*t#f#oto 4466*8#0to*tt##kM*66st#ti!!l4tt•##k'6ks•#!#t•6 <br /> r SECTION 4 • To bo alped at1d elated by an attttiorized Mpresentetive of the treatment, storage, or dis osal facility <br /> ac�tspting (4J)Lk and/or piping. P ' <br /> rFacility Name; <br /> Address• � <br /> ty.� zip; m, h� <br /> Date Tank Received: – <br /> Tot I <br /> r #tlkllo*kstl4##ookwit##!6t•kk�t0tlktt06•rt•tkl!#•►/ltex•1ott40Ysrtoo 0&f0t•#6a•6s6rt6k+•+t60t/t6l6atot06t <br /> tH 4 044 lRevfand 7.10.9x} <br /> 1 Page 10 <br />