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Dec- 12-96 09: 26A Wayne , Perry Inc . 714 523-7880 P .02 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DLSPO=ON TRACKING RECORD <br /> I.aaaaa.a.a............wW Y WY...1..Y..i.//aa W.Y.M.YYWY....Y.a...a.Y.. ................ <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sbeet shall accompany tact tank affued <br /> with its we identifieanon number. The Tank Tracaag Sbeet is to be temmed to Public Health Services Envirooraeatal Health <br /> Division within 30 days of nuance of the tack by the disposal or recycling facliry. The pamit holdQ is responsible for <br /> ensuring that this form is completed and returned. <br /> FACIIITYNAME: \)-1�cv� <br /> FACILITY ADDRESS: l-I Sb 1y, CLun.kat <br /> Si00o <br /> TANK M 139 - /���' -I TANK SIZE - PREVIOUS TANK CONTE*ITS: <br /> aY..aWa........W.AYY.YY.Y.W.IYY./Y..YY WYY/YY.....M..WYY....W............... <br /> SECTION 7 - To be filled out by tank r=Wv%l eonti-acwr. <br /> Tahik Removal Coanaaor. <br /> Odd=s: rr nt Chy: A,MM%? Lx Zip: °101o2I <br /> Phone 1: ( '1 1�) B2Y 03Si Daze Tank Removed: <br /> ..YYY....Y.....Y.YYYW.asr.......... Y.e.Y.Y.YY..W.a.................YYY....Y <br /> SECTION 3 - To be filled out bw eontraeror "decontaminating rank"• <br /> Tank Decontamination Conaaaor Cn V <br /> Address: i4w C,� 0,\,Auq C:ry-. (n4aa.t..ra Zip: 902L14 <br /> Phone 1: ( I 1 b ) . SLS-4113 0 <br /> AnthoriZed representative of conaaeor dying through sivgnamm below that the tank has been deeomamiaaned in an approved <br /> macer as required by Cal EPA. <br /> Name: True: Signmtoe: Daze <br /> ...YY.Y..../..Y.Y.iYY...W WYW....OI..YY.W.W..W..........0/YY.............Y....... <br /> SECTION 4 - To be signed and dated by an.authorized teprocuta ye of the aeamem,:sotnge- or disposal facility <br /> accepting tank and(or Piping. <br /> FxIliryName• SA..., <br /> Address: 32 DO C A Fa.a w,,. S;A "t City: A.v.lw..wm Zip: C)'Ls I b <br /> Phone 1: (1t%� ) TY) -ZL11 <br /> Dare Tank Received: <br /> Name: Tide: -Signature: Due <br /> EH 23 046 (Revised 7!10/96) Page 10 <br />