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r <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - 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 dam of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: iC/7��57r�T 7��1r9y'��'6 Cof't'• <br /> FACILITY ADDRESS: <br /> TANK ID #39 - t✓� Tank Description: 404,9 154e4041 /tl—'eJ t911— <br /> SECTION <br /> 9/LSECTION 2 - To be filled out by tank removal contractor- <br /> Tank Removal Contractor: Sift? <br /> Address: �e3l Ves-r h�f7z�,f 161.0 City: /wpDesry zip: 9s-3557 <br /> Phone #: S—'f-' Or,57-9 Date Tank Removed: <br /> aai#rrr##r#risilirrii#isi###7liii####77#iis#i###sss##irrs#r#7#7iiii##iasarii##7777####ssir###s#!#!###***7#* <br /> SECTION 3 - To be filled out by contractor *decontaminating tank": <br /> Tank Decontamination Contractor. SEGO <br /> Address: f IYI V057-//,f ` City /1laossro zip: <br /> Phone #: ZD SZ y6 S3 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cat EPA- <br /> Signature: Title: <br /> #!#■rrii#iia##sirr*#si#sisa#lirrrriitiissiiiiss##i#!i#*risi#i##rir#ssssss#i######s#iss##77#iiiii#i##ria###* <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: G.AI <br /> Address: '/OIJ City; /T/GH % � Zip: <br /> Phone #: ( D ) 23(, Q646 <br /> Date Tank Received: <br /> Signature: Tide: <br /> ##iii#arriiriiii###ssrrii#####s####s##i#aa##ser!#liisssssi#as#s#!##ss#iss#s##ss##!7#•###sass#iis#ririi#7 <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />