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Dec- 12-96 09: 26A Wayne Perry Inc - 714 5Z3-7880 P . OZ <br /> SAN JOAQUIN COUNTY PUBLIC 8EALTE SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSZITON TRACKING RECORD <br /> ........................................................................................................... <br /> SECTION 1 - Public Healtb Servitts Euvironz=ral Health Division Tank Tracking Sheet shall accompany cacti tank afF.sed <br /> with its sire id=tifirauon number_ The Tank Traclaag Sheer is to be rmuad to Public Health Services Environmental Health <br /> Division 0thin 30 days of ac..eptance of the rank by he disposal or rcycliag facility. The permit holder 3 responsible for <br /> ensuring char this form is compieted and remmed. <br /> FACILITY NAME: \)- �kov\ <br /> FACILITY ADDRESS: t-15D 111 C1ua.k.t <br /> TAtNK M #39 - / �SZ3'Z TANK SIL= . ?REVIOUS TANK CONTENTS: t-A6&60/J��, <br /> SECTION '_ - To be filled out by tank remora! eoorracmr. <br /> Tank Removal Coamecor \,)"N4�IUL� <br /> A t� <br /> .address: 5c7R1 (�,.rtv,p.awAxA� Av- City: Pw. ,✓a?a'7- Zio: °1007.1 <br /> Pbo¢c fi ) 12w-Q3S2_ Due Tank Removed: <br /> .................................................o.o..................................................... <br /> SECTION 3 - To be filled out by contractor "decoumminatin tank": <br /> Tank DCpntatrammon Contractor: (1V A�uriN3 <br /> Address: Li OL Erv� V\n,4&4.A cky! C-16," &A Zip: Cl oZLig <br /> Phone #: ( 31 () > , S2_-Z,-4 130 <br /> Authorized : presentauve of contractor certifying through sigtaturc below that the tank has been decontamiaued m an approved <br /> manncr as required by Cal EPA. <br /> Mame: Title: Siguarrtue: Date <br /> .................e......................................................................................... <br /> SECTION 4 - To be signed and dated by an authorized representative of he treatment, storage, or disposal facility <br /> accepting mck andlor piping. <br /> Faciliry Name: <br /> Address: 32-o0 F e:,� Fero,AAx, S:A...t City: Atr•�,...,v. Zip: c)281 b <br /> Phooc #: (-114 ) 117 -ZL11 <br /> Dace Tank Rereived: <br /> Name: Title: Signarrue: Date <br /> EA 23 046 (Revised 7/10/96) Pagc 10 <br />