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W <br />•tom' <br />UNDERGROUND STORAGE TAM DISPOSITION TRACKING RECORD <br />..•�►+Iii+iiitiiiiiiNi{{{{N{{fi{Ni{{i{{{{{{{�{11N�lNi{N{i!i{!ii{{{iiiiNiii�iii4{iiiiiiiiii►►►►►►, I .. <br />SLCTION 1 - Public Health -S0INIM'jIUMUS AM WIH AGOMMy each lank aMW4 with its situ Identification numtw,. <br />The Tracking Sheet is to be roturraal W Public HWtk SOtY MI 306 22 dai Of ateeptanct of the tank by the dispo:..11 <br />►ccycling facility. The periost holft ii TO;pca"io hN caiYrla�kthal this bra it completed and returned. <br />FACILITY <br />FACILITY ADDRESS: / �� 4144 <br />TANK ID #39 - 12 Q I To" <br />•...►►ssiisiiiiiiiiiiiiiiiii•ii{!i{{ilii!!{iilii!liii�!!ililii!iliiiiiiiiiliisiiiiiliiii.i.i.�►sa•....,... <br />SLC1'ION 2 - To be filled out by tapk r�atraCtor. <br />Tank Removal Contractor: �� 'E. �MCA <br />Address: i� 2 C7 a A ► n <br />- - qty; Zip: <br />phone #: ( -22,01D_Yfo y <br />Dato'I44 <br />..•r►Mt.►�i•iii•ifiiiiiiNlilii#NiiiliiiiiiliNiiiiiiiN►•iNHiiiiiiiNiiii�i♦iiiii�.��i...••...•..� ..... <br />SLcriON 3 - To be filled out by coaUac10r94"n--1aitwtiag ta$:': <br />'Punk Decontamination ContraOWR ('t� <br />Address: 4:219' <br />C~� 1��—U.IQ 1 (� �4.. �..-- p�� c .0 Zip: �_ ... <br />,R • <br />Authorised represe jative thmAh 61pattlro below "t tho tsnk-bas beta decontaminated in .al <br />approved manner u b�( Gti <br />«; <br />'- 'Title. � .�'�• ��= �' <br />Signature• - - -- <br />..►.r.tiiiiiiiiiii•iiiiliiiiiiiliiilililii!{iiiiiii{li�illiiliiiiiiiiiiiiiiiii�iiiiiiiii♦•�►►.�.►►.►••.•• <br />SL,'UFlON 4 - To be signed 90 WO by as atltwOVUW rSptVtgttive of tho treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: Q / <br />L� <br />V.6 <br />zip: <br />Address: pty; t <br />i'hone #: <br />Date Tank Receive): — -- <br />Signature _ _ Title: .. <br />•►►►•isiiiisiiiiiiiililiililiii!<{!{iiliiii!{iNii{1{ilii{iiiiiiil+{•i!liiliiiiisiiiiiiiii►i►+►�.►►►►F.,. <br />EH 23 049 (901644 7-19-92) <br />