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e .. <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *«**ass*ss«ss*«sass«*:.sassss.ass!««««s«**.!*s!s«!!!«!s**«***««««««««««««!s««««!*««««*!«**!«•s•«ssssslos.:« <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 /> e `recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> .s n <br /> FACILITY NAME: i4rco 1- -13 0 <br /> FACILITY ADDRESS: 17 01v !V• El Dorado Poe , <br /> TANK ID #39- /0 9• -- 2 Tank Description: 00 �1` See lefle <br /> SECTION 2 -To be filled out by )tank remo 1 cont actor: 71 <br /> Tank Removal Contractor. t cL vd G. ® <br /> Address' �•0, b, ox 100 City: EZG ®. Zip: <br /> Phone : / r 9� Date Tank Removed: <br /> -To be filled out by contractor"d ntam ating t nk": <br /> TankDecontamination Contractor: i"I rt Q ' <br /> Address: P. O. 10 C 7 City: �` ®, Zip: 9s8�3 <br /> Phone : '¢2 — `9?0 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner required by PA. <br /> Signature: Title: r� r,v f K <br /> r <br /> '«««««s«•!ss!**s**#««!«!!s«s!•!!!!«**ss«tss«#s*s«!*salsa«sssass«*ts««««««s!«M«!«««#!s!*«s!slss!«!t«!ss•••««f , <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage, or disposal facF.lity <br /> accepting tank and/or piping. 7 <br /> Facility Name: 1" f fe i fit e , e G e r a a m � <br /> Address: 3 5"2 5 2 l�V Q, city: ct ®, zip: <br /> Phone #: C <br /> Date Tank Received: " L7 <br /> A /hl <br /> Signatur • Title: Ixf/ d <br /> :•►•s.ss•.•«s.•«ss««««•s«s««s••«•.!«!!!:««!«**s«!««s«!!«*«««««*««!««*««««««*«s*s«!.*«*!!s«:.«s•ss.•s«.•ss <br /> :: <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />