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UNI)I:ItGROIJNU S7'OILACI?'I'ANIC IMPOSITIONTRACKING RECORD rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrsrrrrrrrrrrrr.rrrrrr SECTION 1 - Public Health Services 'Tracking Sheet will accompany each tank affixed with Its site Identification nun•:ber. The Trucking Sheet is to be returned to Public I lealth Services within all days of acceptance of the tank by the disposal or recycling facility. The perrnit holder is responsible for enstiring that this form Is completed and returned. FACILITY NAM FACILITY ADDRESS: TANK ID #39 - Tank Description: O 0000000 O OOO 00OOO*000OOOOO0irrr OOOOOr*0000*00rOrr000r0r0rir0rr0 M O O so 0 r 0 r 0 Err r O O r O r O r O r 0 r r r r 0 r 000 r r►0+r 0OOrr SECTION 2 - To be filled out tank removal contractor: Tank Removal Contractor: Py i >'rcP-V,' C-,- _`'>r;4 r -/ c:i,! L��l"�;�• �� Address:s7 C L!/�lEoi �' (tly:.. .�,k -164 Zip. CEJ L'.-0 Phone #: Dutc "Tank Renurvcl: rr11.•OOOOr OOOOrOOOOrtOOOOrrtOrrOrrriirrciri♦rr•rrrO♦rrrraaeaea+rr rrrr►Err OOO rrrrrieaaeee as etaea eae....ecce• SECTION 3 - To be filled out by contractor 'dccontamirtting tank": Tank Decontamination Contractor: ;��u - Adress: i'�G� 1 4-ICRi ��'i� — City'.;* 'A--tc-t Zip: Phone #:--- Authorized represell approved manln�r as Signature: ractor certifying through signature below that ttte tank has been decontaminated is an �'•1•--c Title: rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr♦*arrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrr SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and//or piping. Facility Name: ' Address: J i� �� City: Zip: Dale'Tank Recei ed: Signature: - --- - - — ---- --- -- ---- --- 00 *404000 0 r r Y r r O r r r•OO r r r r 0 t r E r r 0 0 0 r r 400 r r 0 r r r r r r O O O r r O r r 000 O 00 ♦0000♦ 00 r 000 O O O r O r 00000 r 00 r 0 r 00000005 400 123 049 (Revised 7-10-92) Vous 10 r I