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FSG—lti-1777 U7•Uut 1'1 1-KUI•I I u 14GJZ:D1d(bZ H.ley <br /> ISAN JOA .N COUNTY pLTHLIC EW <br /> ENVMONM,ENrAL HEALT73f DDIVISYON <br /> I1NbERG'tOUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> �wMwwt.W!k wW*t,s+h+kik+:sgr+sFw#w»saa,a,ky.Y�-�ks#hW�*+k#s,w+k+ts+�-yrarur,�,#sgr#+Yks«.rt <br /> SECTION I - public Health Services Euvim `*+` #•�W'�'r «'t#W "* *«' #�.Ww.*:t�, <br /> tztneazal Health Division Task Tracldnd Shect Shall accompany each tank affixed with <br /> its site idettufi on ra n3ber. The Tank Tracking Sbcez is to be rtMrncd to PabUc Health Services Envinpumental Health Division <br /> within 3&da of W=Ptanee of the tank by the al or recycling facility. The <br /> his form i.s compfeted ,and ttaxrncd permit holder is respo=,ble for ensuring that <br /> =ACILITX NAME. # � <br /> ^ACILI'TY AD DRE.S95 /lss C / �'(�/n��D t•,/ y' S <br /> CANTO ID439 TANK SIZE: t PREVIOUS TANK CONTENTS: 12yo 7. <br /> uhwwlcR####*W iMw+kt►tdrt+kw#a�ruhr#ks�h#i**+t�ai+s#�+�►ai##t#sscw#*Mwkac+a#AWry+-t�aFiyr�,...+*fh�kfrtriRh#*ynks=sca*#M�+Yh <br /> 'ECTION 2 -To be fiFlcd out by tank removal coutz-actor: 76 <br /> 'atilt Removal Contractor: _ <br /> `ddr=: I Ci <br /> 1 ty• Zip: <br /> hone bt: - }�:•_se Tank Removed: <br /> W+►#klew*w.rw# �k,RMS#ae*�etryrk+itss,aM*i4srsttyewW wss�KFWs.#�nrtfuY <br /> �'»'-�*WMWw■.♦ttrcWMwlaa�w MrW ik�.+k�tsi r+kW�MK•�sr+kW MrN <br /> ECTION 31- o be filled out by contractor"de conlamf rating tack": <br /> ank Dccbn 'on Conmacmr: <br /> IIS <br /> ddress:lL L(/J� City / /� Zip: l <br /> sons✓#: <br /> uthori=,d rapt Ne of rntu=or cer Eying trough sigaatam below that the tank has been decanzamittated m as approved <br /> saner as iti ed.by Ca!EPA. <br /> nme: <br /> Tube• Signatzsc' Date <br /> s#rikwsw*Mr+ s�e #.w+*,+tC+aftiea.,�*ss+rws*saotswwss+►.se�Cw*s�w�. a+s#*r.#�k,►*� <br /> :CTION'4_J'"signed and dazed <br /> by an mrthOi ized representative of tt?e tmatmeut, storage, or disposal fxMV <br /> ting tank and/or piping- <br /> cility Naim: <br /> (dress: <br /> City: Reel"it .Olyo Z-T- <br /> one #- <br /> to Tank Received. <br /> Title: Signature; Date <br /> .**�a+k+hwrae.i*,y,*.�arrw+�.•s�r.w��lnky.a-r.W W�e�,kMk+r,s:a ra����e«sw <br /> aca-tssc+fWY'+rsyrk MiM sf sick#**t�ssaM�sts-*+k Wars*.t kWWW�s��Y - <br /> 23 046 (Revised 10119/98) Pagc 10 <br /> t <br />