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UNI)EItGROIINI)S7'OltAGI:'1'ANK DISPOSITION 'TRACKING RECOI:D <br />44444►t4tr14►►t►►►►0►00►totrtrrt40r040rrrrtr tt444 t t tri r♦444rrr00t4r♦ttrr4ttt t i t 4► r t r t r 4 t 4 r r t 4 t t t t t 44044 r 4t4 <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with Its site Identification number. <br />'llte Tracking Sheet is to be returned to Public I lealth Services within 30 dors of acceptance of the tank by the disposal or <br />recycling facility. The penult <br />/h�ollder is responsible for ensuring that this form Is completed and returned. <br />FACILITY NAM1::_ <br />FACILITY ADDRESS: 6Z! -47111 e—;' Pot)TSF— <br />�-A <br />TANK ID #39 - _'I'nnk Description: <br />r44tttrr4tr►►►►4ttttt►tttttttrrrrr t4r♦/r4rrrtt0♦r 44YIt4rrt44••••h••Y4t rtt44tt44tt�t 4`4'!4—rf 444t4t44 i4i tq �'4t4tt <br />SECTION 2 - To be filled out y tank removal contractor: <br />Tank Removal Contractor:;'kik-�l��.+F <br />Address: z -o �� l--{%�[L'l i r"f City: Zip: <br />Phone #: cz.—i2v� -"' <br />S�; r-7 Date 'Tank Removed: <br />r•ttrttttttrtrr►t►rr►►►t►rrt4rrrrr►rr4rrrrrrrrrrrrrrr►r4rr4rr4rrr►44trrr4trtrrrrr•4••.e••••q••e•srrr<4trttt <br />SECl'ION 3 - To be filled out by contractor "dec:ontamim ting tank": <br />Tank Decontamination <br />// Contrjactor:��G <br />�4-_ L <br />.ddress: ez-0 god 1 f4(CAI City r�"t7_11C 6--t' - Zip: cft-1 1 - <br />Phone #: (Z*45�7) 4k -q --gs _ _- <br />Authorized represe tractor certifying through signature below that the tank has been deaontarninated it :;n <br />approved man�t r as ket <br />=rbyCaI PA <br />Signature: V 4--- <br />4t4►rrrrrr4ttt4tr►t►rttt4rttrtrrrrt4rr4rr44t4rr4rrvr44•srti4r4r4r•r4rrrrrrt4tra4trtr4r44rr44rrrvtrr4,rrtrat <br />SECTION 4 - To be signed and dated by an authorized representative of ilia treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Nan►e: <br />Address: J i 14 �lv C'_ I _�-- Ctty ukU� 1.'-- Zip: <br />Phone #: i ) 468 ""C7 w epi — <br />Date Tank Received: <br />Signature: <br />'Title: <br />444t4.44444444t•r4044►►44tt4t0tr#t4r4t 4 t 4 r 444 t 4 r 4404 t 4444404r.t 0r v04r0r44t00# t t r t 4444 r r r 4 r t 4 r r r 4 r r t 4: 444 <br />1 23 049 (Revised 7-10-92) Puue 10 <br />