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� D <br /> APR 0 9 1993 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> •••11.11•IIIr1./•p•,q••qt•//•N••r1••IN•••rlpN•tH1••1,1•••p••,H,•••••/per,rr•,w•,•••••••r••••••• <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank afHtt4 with its site identification number. <br /> The Tracking Sheet is to be returned to Public Health 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 NAMIwr r,t r ,-, tZ (JE- - <br /> FACILITY ADDRESS: I 0PAF P �L nOFP 5'I�J?J r r J _ <br /> TANK ID #39 -21;5'Z' -6Z Tank Description: = /iCI0 d <br /> ••••••••/./f••/{•t.,,,••r1./1./t,r•r••11••,rrr••1,•/•t,r••r,•••trt•••r,•I,rrr,111,,,rt•••1••••••••r••..... <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor. <br /> Address: F'ZO /Vo. UA)6m) 7-1p: <br /> Phone #: ( �1 ) �6 y �� 3 Date Tank Removed: - <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank': <br /> Tank Decontamination Conlractor.5-TO cQL-ca+J QF-r-yece- <br /> Address: �?� C/�l/�. UA tc� SSS City: Sr ec0c x d^ Zip: 1I�Zo S� -- <br /> Phone #: ( � )y6� - �-:S33 <br /> Authorized representative.,of contractor certifying through signature below that the tank has been decontaminated in an <br /> approvednne req <br /> Signature: l�S Title:,' S/4-f< c <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 /> I�I Facility Name: VM�e�fn� GALS _- <br /> k <br /> Address:- 740 \ <br /> 1 //�u . �//,l�1 e_S 11� � �yJi-2.P Clly:�1�t�� Zlp:� � <br /> ��Q --- <br /> Phone #: Z �(�� — b 87 <br /> Date Tank eceived 3 -16 / 3 <br /> Signature: T[tle�" 4S <br /> —_.. <br /> i ••••••••1,►•/,•1••p,•••r•rp•p••••/pp••••p••pppp•ppr,••{•rpp pppplpp•.p p•••••••••••• <br /> EX 23 049 (Revised 7-10-92) Peas 10 <br />