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C-0 <br /> JAN 15 1993 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD <br /> ••r•rrr•a„••••,••p•••••••q•,•••r•r•••••••••••H•H1••••,•••••q•p•N•••r••r••,•,••rrr•a•r•,rur•n•••.• <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank amazed with Its site identification number. <br /> The Tracking Sheet is to be returned to Public Health Services within 30 darn of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensur�iin�g�that this form is completed and returned. <br /> FACILITY NAME: <::>( i K—t gZt cel <br /> FACILITY ADDRESS-/0 �( <br /> TANK ID #39 - Tank Description: Z - /, o o p C`;7,4G6-0-„j -- <br /> ..rr••prrr•••••r•••••••••••••r•••••••,••••••••••••H•H•Na•r•rp•••rr••a••r••,r••pr•••••••••••rr.••..... <br /> SECTION 2 - To be filled out by tank removal ntractor. _ <br /> Tank Removal Contractor <br /> Address:s2c) No,, Clio&a ST-, City �7aDLn,kJ zip:!F -00 c— -- <br /> t Phone #: (2c� Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor'deconsting <br /> S--7-0 tank': \ <br /> Tank Decontamination Contractor:=T� til�c_ruVr <br /> Address: �G, U,07,IZ-fE�r� City .'rte r-6"j Zip: <br /> Phone #: (Zo5' ) 3 -- <br /> Authorized rep n hive of contractor ce g through signature below that the tank has been decontaminated in an <br /> approved EPA. <br /> Signature: Title:, --- <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> III' accepting tank and/or <br /> piping. <br /> � / <br /> F Facility Name: <br /> �Cf /3 Y ° —._ <br /> Address: 4C> L `LCA _ W �L_2C� v Clty�i� tLr� Zip: <br /> / <br /> Phone #: <br /> + Date Tank Received: <br /> Signature: Title <br /> Cir„•••p••••••••••••••••NN•rp••••••HNN•qNH•H•Nt•••as••�••r•••r••••as,•rar•r„••••,aa•r•rr••• <br /> EH 23 049 (Rw(ssd 7-10-92) Psas t0 <br />