Laserfiche WebLink
UNDERGROUND S'1'0I6V;E'TANK DISPOSITION '1'ILIC (ING l.l:C(.)I'I) <br />APR 2 `7 19IC9�, - <br />O i i 0 i i 1 0 0 0 i 0 i i 0 i i 0 i 0 i i 0 i i 0 0 t 0 0 0 0 0 1 f/!!♦ 0/ 0 4 1 Y f 1 1 1 t t!. f Y f Y 4 V 4 4. 1 4 1 1 4 0 1. Y Y 0 t 0 V 0 f t t t t i t 0 f f! 1 f f Y 1 Y! t! 1 t 0 v A. <br />SECTION 1 - Public Health Services Tracking Shcet will accompany each t:rnk affixed with its site ldef,,IHPiL, NN4Y7rw�t+ Ab,t /1UH <br />The Tracking Sheet Is to be returned to Public I lealth Services wltlrin 3O (I,ryti of acceptance of the tank t�yl��ii�Tc�t�1�Vl�F� <br />rccycling1ac1llty. The permit holder Is responsible for cnstirinh that this foi Ili is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: (tel �–� �lnr{f'7� �Lrr�" i"; �1"�G•>" �>�" Wil'_ }_ <br />-�---- ---- - <br />'TANK ID #39 - I nk Dcm:ii Iliion; <br />0 0 0 0 0 i 0 0 0 0 i 0 i i i 0 i i i i 0 0 0 0 i 0 0 0 0 0 V 0 0 4 1 1 .. 1 ............ r• ........ a.♦ ...... •.. .. <br />SECTION 2 - To be filled out j)y tank removal contractor: <br />'rank Removal Contractor: <br />Address• �-O <br />• d7 r 1 U,tCity: _-' �� ✓, ==f Uf "Lip: <br />Phone:#: ( )' l)nic'Cank Ref1mvcd: <br />0 0 V i 0 i i i i i i -iii ♦ i i i i i i i i i i V t! V I O I O V f f I V f e. V. 4 4 4 0 4 4 Y V 0 1 .. 4 ...... a ..... I <br />SECTION 3 - To'.be . llled out by contractor "dccontamir>.:+ting tank": <br />Tank Decontamination Contractor:,,,,: <br />.ddress: 'lid (� GJ f�(Ci� �'i-------- ---- -_ CiIV:tt 711): 'i~� <br />Phone #: 4 <br />Authorized repress tractor certifying through sll 11:11me below that file tank has been decontaminated i -;t <br />approved rnan ",las r b Cal <br />Signature: <br />• 0 0 0 0 t 0 0 f 0 0 i i i 0 i i i i i i i 0 i 0 0 0/ f Y V 1 1 1! 1 1 1 1 1 1 ..... ........... .,. ... .. ... ...... 1 0. 1! 4. f. 1 1 .... ♦. I. I I I f 4 .. + .1 . 1 4! f <br />SEC'['ION 4 -To be signed and dated by an anthorized Ili-, tic:itment, storage, or disixos::l fncili "' <br />accepting tank and/or piping. <br />�FacilitYName: � <br />Address: J!� — CiI`'-ra97,¢Kk___7 i 1): < <br />'hone #: ( i ) 468i `Z7. <br />r <br />Date 'TankRece' ed: <br />Signaturc; I Ills': <br />.. 4 1 0 4/ 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 4 0 t 0 f 0 0 0 0 0 4. 0. 0 4 1 .. 1 0 0 0 1 0 4. 0 .. 0 0 4 1 .. .. . 0. •. 1 V 4 0 4 1 0 1 1 1 1! 1 1 1 4 1 4 1 4 4 4 4! 1 0 0 0 0. <br />1 23 049 (Ravleed 7-10-92) 1'"+I° I" <br />a <br />