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dy <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 dans of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensuring that this form Is completed and returned. <br /> FACILITY NAME: 4rco 4W - ft 2/3 0 <br /> FACILITY ADDRESS: :z2o IV o bra0 04 <br /> TAM ID #39- 10!Ll 4 Tank Description: 4 0 0 0 q (0 Pf el �e <br /> SECTION 2 -To be filled out by tan removpl cont actor: <br /> Tank Removal Contractor: -1— riaoq1t? IIWCI 0 � <br /> e.0 2-:31067 �a'C�0 <br /> Address: City: Zip: ?jr_ff 2 <br /> Phone#: <br /> :12 t — 20 Date Tank Removed: <br /> SEMON 3-To be filled out by contractor "d ntam ating t nk": <br /> Tank Decontamination Contractor: —I— it 1 ct 0 <br /> Address:— 0 0 x Z3 0� 7 City: fa?-CDL ZIP: <br /> Phone#: ( T_& z2zo <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner_nrequiredMPLA. <br /> Signature: Title: <br /> SECTION'4 -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: ricel q fe c a e f 421y1 qv <br /> Address: 2Y, —City: aLvZip: <br /> Phone #: <br /> Date Tank Received. <br /> SIgnaturm. 0, Title: /4-12, f 0/ <br /> EH 23 049 (Revised 7-10.92) Page 10 <br />