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r <br /> UNDERGROUND STORAGE TDISPOSITION TRACKING RECORD <br /> «e«ee«««««e«e««««ee«eseessse«a«e«e«:s«e«««esssee«sssssss««:s«sss«««assess««e««««sea«:«««:««««a.«es«sss««ss« <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed 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 d <br /> for ensuring that this form is completed and returned. <br /> FACILITY N 14rco / <br /> _ 1 13 <br /> FACILITY ADD 0 ✓V' 0 rQ Uo J OC <br /> T ID 39- /� -- 1 Tank Description: Q 0 1 0 V ► C- , n 6 ere?foi5z <br /> SECTION 2-To be filled out by taq removpl cont actor: �C�� +e)Tank Removal Contractor: ) i a*1 G. <br /> Address: f F 0, )C 2.3 10� 7 City: Q• Zip: 9"j e2 <br /> J <br /> Phone Date Tank Removed: <br /> -To be filled out by contractor"dnta ° sting ": <br /> Tank Decontamination Con ctor: r' vl • <br /> Address: ® ` 2.3 f �ir City: / ��� Zip: <br /> Phone : '¢ — <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner�p required by PA. <br /> Signature• 0— Title e-y-e <br /> SECTION d -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: r f am q 'Q L'lof _qaeraji4ei40 <br /> Address: 3 5-2 Z wy— Vre• City: S a do., Zip: ' q5-L2_ 3 <br /> Phone #: 2/— <br /> Date Tank Receiv <br /> Signatur ' ! Title: <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />