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UNDERG12OUNU SI'ORAC,I: "I'ANK DISPOSITION "TRACKING RECORD <br />•it♦•ffltf•tfii••fffffiffiifttiif ilitt/rf•rtilf•t•►lr/♦ir►►1lll►•Y/i•lYrtiff•itif •••1 t11•i►it•ri/i•t♦fOtff• <br />SI?MON 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 Iealth Services within 30 dnvs of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for enstiring that this form is completed and returned. <br />FACILITY NAME: <br />FACILITYADDRESS: <br />TANK ID #39 - Tank Description: <br />•ttfti►f►trifi•lttiitiit►t►tra•/lrYi•/Illrla YlrrrflO raaYrfllfat►Ytfl0000f 0000 0f 60000000l000I0 a09a0 to x00!0 <br />SECTION 2 - To be filled outy tank removal contractor: <br />Tank Removal ContrLi—vx- �-,'_`, <br />Address: �aI Ui 1 --- 64 Zip: Z 0 <br />Phone #: (ZQI) qkt "' -,-53-37 Date Tank Removed: <br />•li•/♦ilii i•ffifitffflfi•/ii1/i/ill►ilii•rilllriY/fl••Iiir1Yllal llal lila ar 000 0000a1iirrir•ilii 111.1!<dliit• <br />SECTION 3 - To be filled out by contractor "dec:ontam�pting tank": <br />Tank Decontamination <br />r Conttractor: <br />Adress: ez o rho- lJoircW S -T-. Cit r3 -A-'- tt <br />Phone #: C"?) ZL(-q -- <br />Authorized represell <br />approved manp�r, as <br />Signature <br />Ca <br />r certifying through signature below that the tank has been decontaminated it an <br />Yl1l►ttf ltf iiffff tfftff if if ilillililflfllla♦alfilllaYlflalir•11YlriYalfflllarrrir Y►trarrarrrrarrrrra.. }iasis <br />SECTION 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 />Address: J I' �fi1/�-� ' j' _City: trltlJ� t,' Zip: <br />-- -- - - -- <br />r <br />Date 'Tank Recei ed: 3!'r <br />Signature: _ - -Title: <br />0 0 0 0! 0 4 0 0 0 0 0 0 0 0! r l 0 a 0/! 0 1 0 1 0 0 0 '0 f 0 ) v, f s 0 0 0> e 0 0 0 0 0 0+ 0 0 c O v t 0 0 0 4 6 0 0 0 0 0 0 0 0 0 0 0 0! 0 0 0 f 0 0 0 0 4 d 0 0 f 0 0 0 0 0 f 0 0 0 0 b, " 0 0 <br />123 049 (Revised 7-10-92) PnU, 10 <br />