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I� / UNDEIWItO)UN1) STORACI? TANIC 1)INPOSl•I.1ON TRACKING I21.CO12i) SI?CI'ION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with Its site Identification 11c Tracking Sheet is to be returned to Publlc I Icaltll Services w_ltliln .u1_fln)s of acceptance of the tank by the Qisl)csnl or recycling facility. The permit holder is respolislhlc for c:nsairing th-at alis Rlr m is completed and returned. / P FACILITY NAME: _ _ _(_t'1��--- FACILITY ADDRESS: t�`�� (�j%t'T !�- , �L>rc�"- I ; r. TANK ID #39 - 1 -7 -CAP- 05 _-Tank SECTION1 - To be filled outt gy tank removal contractor: �, k Tank Removal Contractor: L +-Y?_-�i f l_/'I'. Address: !/0 l l ~ _�• —7 �3 •-� -- 1.)atc 'tank Itcnuavcd:Phone #: ............ r r r r r r 4 r r. ......... r r r r r r Y r t Y Y Y r r! r t► r r 4 1 r 4. 4 r 4 r r r r r �• a r r r 4 SECTION -:To be.fllled out by contractor tank Tank Decontaminatlon Contractor:,r�c_ g `r _ r dd ress: g7io o- ZJ N-1 ca(< �'[ - - - - __ _ l r t y <.�� -'rte � — Zip: �� -�`�_• I Authorised represe tractor certifying throul;h signature bolo;:, that the tank has been (Iccontarlllnatcc' an approved man i:as r b Cal 1!)A - Signature. Title: !)A_Signature.Title: Y, Y Y Y Y „♦ ..... 1 ....' .... •, Y, Y Y Y t r Y Y Y 4 1! I r 14 1 r r 1♦ I Y r!! r 1. 1 4 4 1 4 0. 4 1 0 r V 1 1 r 1 1 Y r Y Y r 4 r r r!♦ r r Y r 4! t t t Y r t r!♦ ' O ! 0 0 0 0• i S1?Ci'ION 4 - To.be signed and dated by an aratborlr.ed 1 -111 Ncntat(Nc o1 tine. treatment, storage, or disposal facili r accepting tank and/or piping;. Facility Name: t -I- --.—...--- -tfS---- - ------ - - .._ Address: J_100 00 Date 'Tank 1tecci cd: � 'I•irlt•: ' 1 Y I t Y t Y t Y, Y, Y ... , ... �,,,, Y Y Y Y Y Y Y Y Y 4 V I f/. 4 J 4 1 4 0 4 4 0 4 4 1 4 •1 1 1 1 0 t. e r 0 4 v< 4 V V 5 1 V V V t Y r Y t t! i V 4 4 0 1 r r 4 4 1 1 4 Y 0! ♦•: 'i O V I r 12S 049 (rtuvised 7-10-92)