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Health Depqrfv-nprPu'�- <br />rt <br />ECEI ED <br />JUN 21 2023 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />HEALTH <br />SECTION 1 — S.R. Environmental Health Department's Tank Tracking Sheet shall accompany eacPp�a fltix�d'�lulth its <br />site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 <br />days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this <br />form is completed and returned. <br />/rANK ID # ;0'9 TANK SIZE:/�/ <br />--• i <br />e <br />CONTENTS: <br />r <br />Tank Removal Contractor: rj jov;�/ <br />I A J <br />SECTION 3 - To be filled out by contractor'°decontaminating tank <br />Tank Decontamination Contractor: ®® 9 <br />Address: <br />Name:At/Z 7/ <br />� <br />191 <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 <br />Name: <br />Phone <br />Date Tank Received: <br />Name: Title: <br />W <br />Signature:. <br />Date <br />