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r j'j t'��,l��l•5... � ^ <br />r e. <br />I71AL <br />sr <br />UNDERGROUND SI'ORAGI,. TANIC DISPOSITION 'TRACKING ItECO1:1) Py <br />#r!!tt#tt4tr!ltttttt44tt44!!!4#lttt#OttYrOrYr!#t#!4i###r rtt tY tYttt!#YO#r!#4!4!tlttl4#•tlt4trrt!!!tltYOttlt# <br />SECTION 1 - Public Health Services 'Tracking Sheet will accompany cacti tank affixed with its site Identification number. <br />The Tracking Sheet Is to be returned to Public I Iealth Services within 30 days of acceptance of the tank by the disposal or <br />recycling facility. The penult holder is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: �- r <br />FACILITY ADDRESS: �¢j� ��rl_>?'k��,(►r�� 1=�''��>C�// <br />TANK ID #39 - 1 7j/(C) U 7- Tank Descripiion: <br />v!!t#t4lt!!!tlttrt! N t!#Ytt!#OOYlOvtOstYYSYtYtvYtavrr♦••r4rr•♦rrre•••r••r•••rrrrrtrrrrrsr4•r••rtYr►♦»�rrrst <br />SECTION 2 - To be filled out y tank removal contractor: <br />'rank Removal Contractor: <br />r-,�roc.: <br />Address: La[Eaj c�.�r City: Zip: 'U:� <br />Phone #: (& )_ Date "rank Removed: <br />0r!lrtt44tt!!!tlttttttl tt!!l*Ytr#YOrr►0.#000**rrYYY00/OYOrr0rrr►Y►rFOrtYr#1r YYYYO#rYt►OrY 00Yrtt►l Or0�A#tltt <br />SEM ION 3 - To be filled out by contractor "dec:ontamiqUiting tank": �r <br />Tank Decontaminati�onj Contractor: Gc.k-,-e-*#- .-�il"4<�'_ '%''t-7,�(t��)• �< <br />.ddress: --� 1`�� G--1l�s� City�"2C Zip: <br />Phone #: <br />Authorized represe tractor certifying through signature below that the tank has been decontaminated In an <br />approved manpj ► as ec b Cal P)1. <br />Signature: U �-�- I`�ik--7 iTc -•t� Title: <br />N t•♦rt#t#!!il4t!!!t!4lrt##Ot10lt0#IY♦Os0rrIY0i0rrrrOr00rrir00r0rrr0lt0rYtr0rr r0Y0lYYOt►rYYrOrYr♦rt#:00Y rt• <br />SECI'ION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />i <br />y/� r <br />Address: J �' 1�� �_ ' 1 r_^ City: Zip: <br />Phone #: ( LTi ) �i �s � '/� --- — <br />Date Tank Received: � <br />Signature: <br />.. .. 0 0$ 0 0 0 0 0 r 4 r 0 t O r 0 0 0 0 0 0 r 0 0 0 0 r! 0 0 0 1 0 0 4 0. 0 0 4 0 0 4! 0 0 0 0 0 0 0 6 4 r 4 4 0 i 0 0 0. V 0 0 t 0 0 4 0 0 0 4 0 0 0 O r O r 0 0 0 0 0 0 0 0 6 R 0 0 0 0 0 4 " 0 r <br />123 049 (Revised 7-10-92) <br />Pnf el 10 <br />