REMOVAL 1995 - Laserfiche WebLink

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UNDERGROUND STORAGE. TANK DISPOSITION TRACKING RECORD «rr«rtr«rr«rr«t««ttt««r«r««rr«rr rr4r«4r44 YYr««Y4ttr«r«rsrrr44444 t 44 r t Y Y«r«rr«r«r«««r«Y«r4 r 4 rr«r«t rr rr ,t«t«t SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with Its site Identification number. The Tracking Sheet is to be returned to Public health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: FACILITY ADDRESS: TANK ID #39 - I16(9 , 0 3 Y«r4►4«t«tr«Yrr:t4«d:«.««:«.e4«.... SECTION 2 - To be filled out y tank removalcontractor: Tank Removal Contractor: `eta -,ll.: 7 +�'��1��- .,4 rc:�.� �ts �„ Address:.t� 6a r Who"' ��J`� City: Zip: 6a'5 -z-o � Phone #: ( ) 4t -q —9, Z->-:; Date Tank Removed: ••♦•r«r«••rrrr«tt«r««sr«♦«««rr«rr4s4r•♦44re4rY««YrrrYr♦4r♦4«4Yr4rire4rrr«rY«r«rrr««rrr«rsY4rt«rr«rrere««r«r SECTION 3 - To be filled out by contractor "decontamiq ig tank": Tank Decontamination Contractor: e-. &c:.L-� � e�Ri' � 'C"Tr�t�i E .ddress: (`�� l J o-lCtt City :>"Mek:=MA Zip: Phone #: ne� Authorized represe r certifying through signature below that the tank has been decontaminated ie an approved manpir as k rJ-b7C�a�-11�1 Signature: F(�c Title:„S iri44444r 44«rY««t«r«r«««t«r44r4►«4ti•44 iYei44e44ir 44r41i4eee4+e•Y4YM44♦rr YrYrYYtrt YrM Yel4444Y4rr4Yr+s.+«Y rtr SECI'ION 4 - Facility Name: To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. kl� 5-/00 � •�- Address: J ! 00 -Zw cF-- City:_ "Lip: Phone #: (,Zoq ) 6 6 k Date Tank I2eceivq: :5 Signature Title: ++++++ssYss«r«rrrr•«««t•««r«r«rY«i«is4s44r4rM4r4rrrs•4ri4rrrrr+4Yv4♦r+rrY4444srrYrtrY44i+4ir4«rr4r«s�rsr 1 23 049 (Revised 7-10-92) Page 10 1/