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UNDERGROUND STORAGE TANK DISPOSITION TRACKING. RECOI:D <br />►►►►ittt►t►lttt►tt t tttt tti li l►►►l 44 Y 1•i l Y l►iii►►►i i it il4►Y►e4i Yi li4►►♦4►►ltitli►t t 0►40► 44► l► Y► l t l t 49 i,►t•tt <br />SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with Its site Identification number. <br />'17te Tracking Sheet Is to be returned to Public I lealth Services within 30 days of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form Is completed and returned. <br />FACILITY NAME:_1���t1-��d-'f� T - -- --- - <br />FACILITY ADDRESS: <br />'TANK ID #39 - 1:7C <br />► l► 0 i l• l l l l t i l l 4 l►► i i i►► i i►•► Y Y 4 4 Y► Y i e• Y e 0 e i f i i i Y 9 Y 0 b Y Y Y 9 4 Y 9! 9 9 9 9 Y 9 O 9 Y 9 b V 9 V b 9 V b b b b b 9 9 6 9 b 9 b! 9 b 9 9 9 9 b b' 9 0 9 b i <br />SECTION 2 - To be filled out y tank removal contractor: <br />'Tank Removal Contractor: -fir <br />Address: z -,O & fr � 1 ` "1. City: � ��JLnUr.( Zip: <br />Phone #: ( ) /'9.S S ; Date Tank Removed: <br />•►•►l►ttttt►ttttttttttttti►►••♦iiieii44YiiYY4liiei►ii►4 Yiiieeloo901bbPbbblbbilte 9996b bb99999999 bl9boii Yill <br />SECTION 3 - To be filled out by contractor "decontaminpting tank"- <br />G . <br />Tank Decontaminati�on( Conttractor:,��G� <br />.ddress: OZ -0 1`��'� z t tfcd City: -(UC 6-C•tt Zip: 1Szn.s-- <br />Phone #: <br />Authorized represetl <br />approved manpir, as <br />Signature: <br />r certifying through signature below that the tank has been decontaminated h an <br />•i►•ii►44 ►iti•iitti►l►lli•�i�ti►♦14YY99e YYYY1il9tY999V•VV9b+YI!!!9!il44►►►•►4►•iii Yl l4 ♦1iit4•il►►•4 tie dit l►• <br />SECI'ION 4 - To be signed and dated by an authorized represenintive of the treatment, storage, or disposal facility <br />accepting tank and//or Piping. <br />Facility Nanlc: Y`► C—�'>%>i'�'1,�-t�j� - pct r�' <br />Address: Cityujzl-l_ �� Zip:�, ---� <br />Phone #: <br />Date Tank Recc' ed: <br />Signature: <br />V t i V V! t t 9 P 9 Y 6 Y 9!! 9 i! i i l ► 4 e e f Y Y i! 0! t 9 6 J V t V O J 9 7 4 0 'J 0 V 0 V 0 0 8 4 V 9 Vv 9 0 i V e V +1 S e V b 4 9! 0 0 V b 9 Y 9 b 9 9 d♦ b 9 V d b! 0 9 9 9 9 P 7 9 <br />1 23 049 (Rovfsed 7-10-92) Pn), 10 <br />Hdl <br />I <br />