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UN1)I:RGROUNI) STORAGE'1'ANK I)INPOSITION TRACKING RECUIill <br />• I I I I I t/ 1 1 1 Y 1 1 1 1\ t 1 1 t t/ t,/ / t R t R 1 Y t R! r Y R Y! r! i r R Y r Y Y 1 Y Y 1 i Y r r r a V a i i i r• i Y i e f• Y Y R! t R t Y! R R i r R r i Y R f Y i Y Y Y Y! f••t r r f <br />SRC1'ION 1 - Public Health Services 'Tracking; Sheet will necompany cads tank affixed with its site Identificat[on nun:i)cr. <br />The Tracking Sheet Is to be returned to Public I Ica1111 Services wltitln 30 dillsof acceptance of the tank by the dtsi)(- c<tl or <br />recycling facility. The penult holder is responsible for ensuring; that this form Is completed and returned. <br />FACILITY NAME:'fA YFC- y\_j <br />• <br />FACILITY ADDRESS:. <br />'I'ANK':ID #39 - � �'--'I'nnk 1>tacriilltc�n: r�j��_ �i������t•t�j.=�_�J�,��P�r.-� J <br />/• I Y Y R Y Y I Y Y I I I t► t t t t I t t R 1 1/ t►!•• Y• V r e e e Y• e f a i i Y e i. i••••• i r r• i•••.••• r i r !ria !! r f rr i-Y�Y'r'-"f Y r f f r f Y! Y r Y f f i r r •.: =a r7�r Y—• <br />SECTION 2 -,To be'tillcd out by tank removal contractor: <br />Tank'Rcmoval Contractor: ` <br />Address: City:_ f�'_�' K—i` �'t( Zip'0 r <br />Phone #- cza ) w S _ Date Tank Rcmoved: <br />a•YiYiiiRrIYYYYYItttttlt1111Y1RYirrrYffifrfrfifieiei•eeiraae•i•••e•i•r•rriiiiir►aarrrrarrrara0rrrA��'..aarrYj <br />SECTION, 3'- To be filled out by contractor "dccontaminating tank": / <br />Tank Decontamination Contraetor:,G- ' k: a <br />.ddress: �Z�. (`��' (.-! NI Cd <br />Phone # <br />Authorized represA'r <br />ractor certifying; through signature; below that the tank has been decontaminated it <br />approved man cCal 11 <br />Signature: <br />Y• f Y a Y Y Y 1 Y Y Y t Y 1 1 1 1 1 1 t 1 1 i 1 Y R! i i a r r i t e Y r r•• f♦ a e e• r 1 i r e e•♦ a e a J! r• f• 4!•• 1• a 1 r! r i f/ r r r r►• ... . ... .. .. ••►• i <br />SrCI'ION 4 - To be signed and dated by an nntltorized relu•csvntatlw• of the treatnient, storage, or disposal facility <br />accepting tank and/or piping. <br />X� ; <br />facility Nante: �O'>�� _�r�ct' t�- _S/V�[,.r5 <br />Address: '5700 <br />I'hone #: (7-19y, <br />Date Tank Received: <br />Signature: J <br />_'1'it1e: <br />zip: <br />a I) <br />�rrrR• <br />I <br />a , <br />� �.. .. ••.•• r i• i r r r e! a r i i i• r i•. r.• o .. � 4. e � .. . �• {v . r l' 4 .. 4. f Y. 4 .. o. c c •i >. � 0 4♦ .. ! .. e r a r r a e r r r a e r r 1► a a a.+ s •. i t <br />125 049 (R(!vleed I-10-92) Pnpn 10 <br />