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Jul, 22. 2013 9:33AM - - NNo. 3182 pp. 4 <br /> ENVIRONMENTAL HEALTII DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Teloplrotpe,(209)468.3420 Fait: (209)468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> tHNalttana»au1»\taH\H\n'aflHaftumaHHHaHtnaaffaaf H'aafanHftlntH»nHHHetaHHHan»H ' <br /> SECTION 7 -SIM FriAronmontal Health Deparlmenl's Tank Tracking Shoo( shall accompany oath tank affixed with Ile alto <br /> Identification number, The Tank Tnicking Sheet Is to be returned to the EnAronmemal Health Department)Mllhln 70 davo of <br /> accepfanoa of The tank by(he dkrposal or roeyogng facility. The permit holder Is responsible for enuring that this form Is completed <br /> and returned- <br /> FACILITY NAME: <br /> FACILITY ADDRESS <br /> TANK IDfl39- +'•y/a7'jA'�O r RNK81Z13;,lQ,,,�PRI:VIOUSTANK OONTENTS;_ Il,,316 <br /> ***kA#**k*t*****Yt}'It}R#*R**'MYkk'r"Mk'�kk*i**k�FhF*kR*f**#**M*%*YnPw#**k*Yik*xxx*kx5lkxwww*i-Y�P�\wiYkKWx{y�*•y#w#x <br /> SECTION 2-Tobe filled out by tank removal contractor: <br /> Tank Removal Conkeclor. ✓ •G <br /> Addraes f7 Hd fi skit$ CRY:• SR4 0 zip: 115 <br /> Phone ff;(�.�y�5'6�?a Date Tank Removed, �'/ <br /> *******#tit*#,Yi�FiRNM*•44wfMWXkwvtk}rwWR#iw*^kNik}4xxx*wxtfwA*x*Wwxxxxwxxwwxx xiwtw#iwwxwx#w+xxwxwwaxxw.,ykwawifFk <br /> SECTION a-To he filled out by contractor"decontaminating tank'`. <br /> Tank Decontamination Conttacloc' A(ag curs JuyulaGs <br /> Address: Ync/'' Abewaj4 LAG city a r � zip: 1�?N� <br /> phane ti. _j <br /> Aulhodzad representative of contractor cerillymy through signature below that the lank hes been deconleminaled In an approved <br /> manners requkedbyCal PA, <br /> Nome; •A TNIe; .\1 1�t "( Signature•. Q. 9�jed�JG�DOIe�G' 9 Q -_13 <br /> ***!c*k:1*w*aNkA*ikX*wk*k*xrks***f##wa****wlvx*civ*tit*a#rt+ra,rt*x#''rrrk*t+ar+*Fran*xax>Yna+++rwxktrwrA*+rr;xekw <br /> MOTION 4.To be signed and dated by an authorized repraaenladve of the fmalnenl,storage,or disposal fooillty <br /> accepting lank and/or piping. <br /> Facility Nama{^ZSA / S -_�c It to� <br /> Addresa:__9/0/ 6d00,61,r4mWe e) L✓492 City:�_zfp:226&7.�.._., <br /> ,'hone fl; 1400 ) qq(4 - 31 r4 <br /> Date1'ank Received; <br /> NBme,, �lr'-r+�� Tlue: V 5ignsWre: Oats <br /> PH 23 046 (ReviRed l0/30/!2) 9 <br />