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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> LNVIRON vMNTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE T.LNK DISPOSITION TRACKING RECORD <br /> r.rrr.rr....rrrrrrr..vu..orso...... srrrrvr..rror.00....r.rf..ror...ro........vo r...wr.r.. r <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affizcd <br /> with its site identification number. The Tank Tracking Sheer is to be returned to Public Health Services Environmental Health <br /> Division within 30 davS of acceptance of the tank by the disposal or recycling facility. The permit bolder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: AA - A Y-1- <br /> FACILITY <br /> TFACILITY ADDRESS: 3 1 3 3 W. A d A rT R o4a, 5 7 o cO o ti <br /> TANK ID 139 - TANK SIZE: 3100 0 9 q I PREVIOUS TANK CONTENTS: 5,k <br /> .w...ro..............orr..r...............rv....................r.r.............r....................... <br /> SECTION 2 - To be Ued out by tank removal contractor. <br /> act <br /> Tank Removal Contror. A4yam cad 6 eo l n V'1 roh m-tolq 1 , :r N C <br /> Address: HOOS IV- Wilson V/OL City: 5T0 (K10h Zip: 95.20 � <br /> Phone n: ( ;kD ) tl 6 7 - 100 6 Date -all Removed: <br /> _ ........................................................................................................... <br /> SECTION 3 - To be filled out by contrarror "decontaminating tank": <br /> Tank Decontamination Contractor: A va K e 'tc/ (7-00 p N V i N o h s9 'N y4 l ; X N C - <br /> Address: Kooy N• Wilson WgV cry: 57ocK1ovl zip: 95A05 <br /> Phone s: ( � 0 > q 6 7 - ► 006 <br /> Authorized :epresentz6ve of contractor c_^irying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> r r <br /> Name: �aVla Mtls; b6a�1 Tit'.e: 3auJer fy.r� ��o1olMSignztur. �N^ Yt- Date 4 <br /> ..............................r...........au.......................r...........r.........r............... <br /> SECTION 4 - To be signed and dared by an authorized representative of the n-eatment, storage• or disposal facility <br /> accepting tank and/or pipi g. <br /> FaciliryName: WAST CaaST (= 9 u;p Mss j <br /> Address:-57 100 r�ylor Covey ciry: �urloel( Zip: 9535 ] <br /> Phone 9: ( 86O ) Nyl - gy y � <br /> Date Tank R eived: <br /> Name. i, Title: -p,4-t4 . Signatur ` Date 7 '-.2r-PLq <br /> ....r.w..........r.........................r................................r............................ <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />