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i UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD - ' sttstttsttsssstsssttttttssstssststsattstststssttttsssttsttttttttssttttttttttttststtssttstttsstssttstttsttst SisC WON 1 -Public Health Services'hacking Sheet win accompany each tank afted with Its site ldentilieation IU Tracking Sheet is to be returned to Public Health Services Wombat. withla 30 dan o!acceptance of the tank B thdltq►• The permit holder is responsible for ensuring that this form is Completed and returned,&the disposal or FACILITY NAME: :� 7t2iT FACILnT ADDRESS: TANK ID #39-.Lo G C - o t _Tank Descriptlon: ( t E S � •sttassststssssstssssssttttttttttsst•ttssttat•t•cent•ttts•s•ststs•sststts.ttttttttttsttttsttstttttts•sttttt• SSCnON 2-To be tilled out by tank removal contractor. Tank Removal Contractor.5:c,e�,z•,.��✓![x- -�-- ��c � - ! .4 3 r Phone F: 0k, q*e S 3�3 Date Tank Removed: .tt...t...t.t....t..t.....t.....t....•...t.t..tt.tt...t...•...t...........t......t.........t............•.. • SWn0N 3-To be RUM out by contractor"decontapninating tank": Tank Decontamination Contractor.'S eclGTa 1. f 1/t C¢ '��-t-. - J �^ tam �• A�teas: Ci n• rL>.� (/t> Cltr rug./ ra.i _ ZIp,7 S�ze- Phone *: ( ) -X15 5—'J3 Authorized representative of contractor Certifying through signature below that the tank has been decontaminated in an . approved manner as required by Cat EPA Slgnsture: Title: t•ss•t•tttsttsts•t•sttstt�tttt••stt•ttt•t•tttttsalt••••ststtttstasty.•tsttttttttttts•tst•t•tt•tttttsss•ttt• 92MON 4-To>m signed and dated b7 an authorized representative of the treatment,storage,or disposal facility w •accepting tank and/or pipin& Facility Name:�'AL Address:/5316f•.yiy �� City:- 2iocic: zt ' �� -f-, p: Phone #: (Z4ee , Date Tank Rene / 59" Stgttature: YL Title: v ttttstttats. ••t/tattsatt••tttttssssss•alt•ttts••t•tts..ts•s•ssts•t••tsta•tsststtsst•tttsstttt•stt••..t• r IN 23 049 tRevleed 7-,10-92) Paye 10