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UNDERGROUND STORAGI,. "I'ANIC i)1S1'OS1'I'lON "I'ItACKING RI'sCOI;I) <br />r • ******#** ♦ • ! v ► ► ► r ♦ r ► ► • • • ► r ► ► ► ► r ► ► r r r • « ► • r r • ► • r r 0 0 r r ► 0 r ► ► 0 r r • r ► ► • ► ► ► • r • ► ► « r ► ► ► r r • ► ► ► ► ► ► *I I***** ,1 <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site Identification nu!, uer. j <br />The Tracking Sheet Is to be returned to Public I Icalth Services wlthin 30 dnys of acwptance of the tank by the dlsp,'.s'11 or <br />recycling facility. The permit holder is responsible for enstiring that this form Is completed and returned. <br />FACILITY NAME:-f�lij�/_ �- -1'`f d'1[ <br />FACILITY ADDRESS: G,7 ap <br />TANK ID #39 - f qNO 0 3 'funk De-scription:�.427,, �i. �Lt _ 'l -AA-!; Lim IZ�- a <br />•►��►���������ts�����st►•��►►►►r►rtrr«►►r►►r►♦r►►rrr«r«rrrrr«►rr«rrv►r«rrrrrrr►«►►r►►rrrr►r «r►►vr►0 <br />SECTION 2 - To be filled out gy tank removal contractor: <br />Tank Removal Contractor:rteti, <br />Address- City: t-6 zip: <br />Phone #: Uttte "funk Rcmuvctl: _ <br />•►►►�•��►/ �/ �/ j j�� r y♦/��•► r► r r r r r r r r r« r« r r« O r« r r« 0«« ►rrr 0• I r r r O r r r r Y 0 0 r r r r r r► r r r r► r►«« «rrr 4 0 r r I r r r r O c r r r r r► ' <br />SECTION 3.-'To'be.filled out by contractor "decontantipting tank": C - <br />Tank Decontamination Contractor:,G�t��t(- <br />Adress:Z.0 go- IJ tt, C4 Cit ` TbCt�t� "Li i• <br />Phone #: Zor <br />() <br />Authorized represe tractor certifying through signature below that the tank has been decontaminated an <br />approved maxi. has: e r b Cal P <br />Signature�- _ "Title: <br />r►r►t►►���•►�Mt���ft•*►►�►►r►►►►►r►rrrr♦rrr«rrrrrr««►rrr♦«ar««rr««r«rr•r►r►r►►►r►rr«rvrrrrr««rrrrr«.:ca«rsr�� <br />SECI'ION 4 - To be signed and dated by an authorized represenlutive. of III(', treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Address: <br />Zip: <br />/ - -- -� <br />Date Tank Receiv• : <br />Signature: Title: <br />r r$ r r 4 r 0 0 0 r r►► r► t r* 0► 0 r►►► r 0 r r r►► r r r« O O O r 0 0 0 0 0« 0 0« 0 O O r r 0 0 0 r 0 0 0 r. 0 0 0 0 O r 0 0 r r 0 0 r r r r► 0 0 0 r r r r O r r« r 0► 0 0 ,. r r r <br />'1 23 049 (Revised 7-10-92) 1111un 10 <br />t <br />y <br />