COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

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P UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD *sass.•««««««•«ss«*ss««+•+«.asses««:s«••«sssssss«s•sss•ssss•ssss««sssssss•«••s••««sass««••ss«+•sssss••:s•:s SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet Is to be returned to Public Health Services within 30 dans of acceptance of the tank by the disposal or F recycling facility. The Permit holder Is responsible for epsuring that this form is completed and returned. FACILITY N f 0"r r Co tlW - PW 2130 FACILITY ADD 06 Al.P o ra d o '"" J O e, ®4 TANK ID #39- l Q "--3 Tank Description: o Q 61 ( 4f ea O e r • *s«•«sssssssssssss+ss•«sss«ss•s•««ssssr:ssssr«s•««s«s««ar«„ass««s«assass«s««s«sssssss•s•s•ss«ss•s«•*ass+ss•• SECTION 2 -To be filled out by tank remo 1cont actor: j Tank Removal Contractor. r i Q vl M ., ® etc ra K4 f H+v .Address: ' .0. 60K 231062 City:_'a_c�0- Zip: P Phone #: 4Z/ — !Z 9a Date Tank Removed: s••s•sss*••asses:«ass*«.«*s••••s.s«•.ss•s«••s«s«sass•««ss««««•••s««•« «sass«.••s«•ss«s«.•sss••s««•s.*s•s•s• SECTI ON 3-To be filled out by contractor "d contam ating t nk": Tank Decontamination n ctor. r vt0 Address:- 4 `4 2 L_�° 7 City: _tel , / ®� Zip: Phone #: ( '�� — LZ 1 U Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an Approved manner�p required b PA. , Signature: Title: Pre 51'v f 'f t4+— SECTION SECTION d -To be signed and dated by an authorized representative of the treatment,storage, or disposal facility accepting tank and/or piping. Facility Name: rfamq fq C (/t Q P ® _ c e raw am+0 Address: 3 S 2 5w 2 *q V e City: ado, zip: Phone #• X21-- 1 f7 U Date Tank Receiv R_ 3 C3/Ad Irl i. Signatur ° Title: 1121 �. s*•s•ss•esss•••ss*«•••*•s*s•••*««s««s«««sssssssss•ss«s«s««««•s««««ass«••+s•s«ss«s•s•s««•«s•«•••••«s•s*•• i EN 23 049 (Revised 7-10-42) Paget 10