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05/10A9 09: 19 FAX 425 251 8782BARGHAUSEN R004 <br /> ' SAN SOAQUAIN COUN Y PUBLIC HEALTH SERVICES <br /> E"9RONN ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DLSPOSMON TRACEING RECORD <br /> r.ta+tYtr r,r rtrrV"r—T—��W.b+ra r�{n4�tra�fs+kMurt��nMsvfisrrtl4. ««r+----"tM+Ml�fnY.tr<ra*�{[�ef[frFf�f�r+YWrb.r;tMF <br /> SEMON I - Public Hcalth Sevicrs Emviron to Healdr Division Tank Tr mldng Suet shall a==parry eu:h Lank affixed With <br /> its size WTd&&doa m=bcr. The Tank Ttwicing Sb=is to be rc=nrd to Public Health Sctviccs Emiroamcntat Ffcalth Division <br /> within 30! of acccpCaace of tic tank by the disposal or rtcyciing faclity. Ttrc permit holder is rt=onsr'ble for=S,+TMg that <br /> chis form is tered and zenumci <br /> ?ACIL"4 rY N LME: ;�'�7011 <br /> aculrir AL DRESS: 44 <br /> SANK a�M TANK SIZE 1 PREVIOUS TANK CONTENTS: <br /> +warttr«sw.t. aw.r+kwss.orrraritrwr.r+trtr..�M}rr � <br /> 111111 "44tw.rc.tla,�kMs.R w,a.wa►a�wur�asia�r.4wrtsr+wlsfe+�..�rtW Y+Ya <br /> EkMON B-To be-Hcd vtu by tank rrimo•al cmu-4cto= -- — - - --- -- - - -- <br /> 'anic Rcmoval&nt aaer. (qEi TLE, RY,4,,l <br /> .ddr=: k-74-7 _!L f&ed -GkLI2 7� City: Du 4 i N Zip: <br /> i <br /> Dare Tank Remavcd: <br /> r+�+4+N Wrssr�MW+Ysr4ssyr.ywscrrwc4Iyeti[vr.trsr+YMrJirr,r w�.Y iY�irarY.WanYreatr.�rRW+M+4 <br /> EC-ITON 3.- o be frlled out by co�ar"decontanift a��tank": !/�vQC2 T <br /> ank Dccon oa r� <br /> ! CAIItT'aC'Jgr' C <br /> ddress: ��c/l� air z1". <br /> 21n: <br /> -Iona ca 93 <br /> urh4riZad rip 'Vt-of coamacxor=tfy*`through bciow that the rank lras beau diaa=nmatrd is aa approved <br /> armor is' .by CA EPA. <br /> Tule- S"rgaat�a c: Date <br /> - - rwr.+�+*yn•.aulatwww saaa.�wwas <br /> =ON'4- be signed and dated by an authorized mpreswm&e of tht <br /> u�atmcn:,storage, ar aasposal fac•7iry <br /> ;accqnug task a="Or ping. <br /> trZity Nan¢t: EG� <br /> Idris, City: Zip: <br /> oae 4F: --- ' z3s- i3�3 <br /> tz Tank Recxi;ed: <br /> mc: Tule sign== Dare <br /> A a»<tacM r rr«.1.,tapYrr w..rarr.��tra.,uh,aanw.r+�rya.r.casrar.arr+o�+ar�r#W.pksTat,ta.arrant*..Sam.rr r sasYMrv..rr a..i W W rs.caar <br /> i <br /> 23 046 (Revises WiI9l98 Pagc 10 <br />