REMOVAL 1995 - Laserfiche WebLink

Home Browse Search

UNI)BIWIZOUNU S•I'ORACE •PANIC DVI POSITMN TRACKING RECORD 1 o r 1/ 9 r r SECTION 1 - Public Health Services Tracking Sheet will accomp:uly cac:h tank affixed with Its site Identi(icatfoil nur cr: '116`VT cking Sheet Is to be returned to Public 1 lealth Services w(thln 311_dn_y_; of acceptance of the tank by the dlsp� :.1 or .0 recycl(ng facility. The permit holder Is responsible for ensairing that this fours Is completed and returned. - 1 Q, {. FACILITY NAME: ------- --- r ' FACILITY ADDRESS: TANK ID #39- 0 39- r Y r r r r r r r r t r t t r t r 0 r Y r r r Y r r r Y e 0 1 r 0 1. Y ... 1., r ..... 0 ... .... .. ... V. .. ... .... f SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor:TA y'• E .._� 4 -. _(c_. Zip:— , r Phone #: Date Tank i:cnuwcd: - - Y r r r t t t t t t�� t t t t� t t t t• t t t t t r r t r r t r r Y Y Y r r r r Y r e r r r r Y Y Y r e Y r r Y Y 4 0 Y e 1 r J Y 4 1 4 r Y Y Y r Y r r Y r r r r r r r r r Y Y Y Y r Y r Y Y Y r Y '. Y Y r� t SirC1I6N 3 -T6' -b8 fllled out by contractor "decontartlinaling tank": 'Tank Decontamlittitlon Contractor: Adres g7�U� G-! N cdK'-tt t� 7.1 phone #: Authorized .regr.as, Wrb ertifying th,ou[,11 %//;nadide hckw-, Omt the tank has been deconlanllnated i approved man�Signature:- --1- `+ Title: r Y r e 1 r r 1 Y Y Y t t t t r t t t t t I r t Y r r r r Y Y Y r 1 r r 1 1 Y r J 1. 1 0 J 1 1 Y Y Y 1 Y. 0 1.1.0.4. . J. =i 1 !• 4 Y Y Yee 1 e e 1 Y r e e r Y/ 1 e Y 1 e Y Y 1 Y Y 1 e e e Y vf SI:CI•ION 4 - To be signed and dated by an antiorl-zed relrrrscntntlrc of (hc nemnaetlt, storage, or disposal facility accepting tank and/or piping;. facility Nante: Y� �� __.I.s Address: Signature: . r e 1 Y r r I r Y r r Y t r t r t r t I t t t Y r r t I r r Y r Y o r. r. 1 Y o 1. 1 r. 1 9 9, Y e 9 V v. .. i v S 1. 4 4.♦ i Y r 1 1 r 1 1 1 Y Y e r Y r M1 r I r 1 e 1 1! e 1 Y. e n P Y 1 23 049 (Revised 7-10-92) P.1y, I11