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14 <br />0 <br />UNDERGROUND STORAGIC TAU DISPOSITION TRACKING RECORD <br />.•>+ww•�:�••{iiiiiiiiNili!!!!!!!!N!!i!!0!:='Q�!!tiNIMlNlN{ttliNii{N{{N{/{{iiiNil�w►�wa+w� •►�. , , , . <br />SECTION I. - Public Healtb-SgyY = TwMal &boot wM IiGQIIAtpay wcb W* Wired with its alto identificadun atimk,t:.. <br />The Tracking Sheet is to bC retttr W to Pitb* HWtb Sonj= VOW 42 dM PI 9=ptanei of tho tank by the dispw-ai .• <br />,cycling facility. Tite permit boltfw• b ratpgatibla for tltiWia,A,tbit Wit font► It completed and returned. <br />FACILITY <br />FACILITY ADDRESS: 1 G <br />'TANK ID #39 - 1:1> , Twa <br />•.•s••w••♦•w••satii�wiiiitliiiiiifftitititiiiMtitttt�tiilisiii�iii{iiiii•i•ww•••siitiswwws••,•••..••....,. <br />SLLI'ION 2 - To be filled out by rW11oOtriGtor: <br />Tank Removal Contractor: �r - - <br />�1 <br />Address — I-�____,_�,� ams u�ar -- c'Zip: <br />Phone #:�DaW Titlk ACMYed: <br />..••••w••ww•w•wwww�iwi�iiififiii{i{•iii•iii!•{!ilii{illi{!i{isiiiiiiiiisawiiw •♦�www�wwwwww•w••••..•••..,.... <br />Sl:CCION 3 - To be filled out by Q0 Uractor 94e00Rtaiginatinj war: <br />'1'auk Decontamination C0Q1MGto r- v�/���1'�t%� <br />Address: Is a"q':j' tip: <br />Thune #: �) �(-�. e�w�ea•� ee ne— _ . <br />Authorized represe lativG-coatrt —0 c ilyiuj tbroajb tijatltura below that Wo tank tilts been decontaminated in <br />approved an er u' bX Cal <br />Title:5—; <br />.••••ww•wwwlw�w•�{•ii{{iiiiiiiiili{{!ilii{li{♦1!{iii{tiliiiiiiii•i{iisii��ii•�i�iiwiwww•�www•••��>���••••• <br />St;MON 4 - To be signed go 4&10 by t1A SutborbW MpRMWj&t1Ya of tho treatment, storage, or disposal facility <br />accepting tank &adAw plpia& <br />Facility Name: <br />:�ddress:1�00 L` pry: zip. 53 O <br />77— <br />Phone, #: 1cSL-1--P FF <br />L4� 14 <br />Date Tank ReceiYed: -- <br />' Title: ' <br />,Signawre:-------- <br />-. L <br />••••w•wwwwwwww•ii{i�il{iilltiililtlilt/lllllliliiliiiiiii{ilii/{ii�iiiiiriii»•i�awwi•iwwwwwaws•>•••.•«..a <br />EH 23 049 (Rtvtiid 7.10-9�i) <br />