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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 days 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: <br /> FACILITY ADDRESS: O Y L-�` , 53�� <br /> TANK ID #39 - Tank Description: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: t�-o tJ+ 4UVj(oV\ City: Zip: <br /> Phone #: ( 001 ) -4k(04-y333 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontarmri t g tank": <br /> Tank Decontamination ContractorrDck Q tir a� .0 T�T� �w AE7� �" `+ '"� <br /> Address: �O/ ��rOfn,43 � Ciry.src Lia" Zip: <br /> Phone #: <br /> Authorized repr entati f contractor certifying through signature below that the tank has been decontaminated in an <br /> approved m e req ed by A <br /> Signature: Title:-, <br /> »fififi+iris*+}#t*x##ilii#}#liixrt#}}lilt*»+#riff»*#+si*ti}#i##*»rrrfir*+}}iixi»+t}+tt##»»#iittrt}#+}#i#t##it##»»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 - f�a f�j � ll <br /> Address: /��O AIA-, a/tom CityL­roe�N Zip: Z�3 <br /> Phone #: (�� ) Cly -S� 2/ <br /> Date Taak-Xeceived:,? -'2-j-q <br /> Signature: �c Title: <br /> EH 23 049 (Revised 7-10-92) Page 10 <br /> I <br /> Is • <br />