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w11♦ cuuu V�;Ul bb"JUZ DOLORES BAPTISTA <br />MAY -30-2000 10:15 - <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />FNVUtONMENTAI- HEALTH OIVimm <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKIIVG RZCORD <br />PAGE 02 <br />P.03 <br />.......................................«........«......................,...................,...«.N........ <br />SECTION 1 -Public Htedtit Serviw Envlronmcmal Health Division Tank Tracking Sheet shall accompany each tanlL"fued <br />with its site identification number. The Tank Tracking Sheet , to be returned to Public Health Smites Fnviroeumrttzrif lQt <br />Division nithla 30 dam of acceptance of the tank by the dlaposal or recycling facility The permit holder is mponsibla-for <br />rnsuring that this forth is completed and returned <br />FACILITY NAME: <br />FACILITY ADDRESS' <br />TANK ID 139TANK SIZE 44;�_i>C_ PREVIOUS TANK CONTENTS 7 VKKn 04(a <br />.......w............................ ........ .w..ww............ ...•..•«.......•Y•........tl......o..pww <br />SECTION 2 - To be rifled out by tank removal contractor <br />Tank Removal C'rmr�rae/ter .S- ;/�.5- /L. �j�i�Yrc:L<� Y t1 �';65._ Q. [ . <br />nklreu+5mLt 87 f�Ll2r i�, t ray` r;C1e( Zip• <br />Phone N: f-�`I ({% f iS- 1 -- - Dnc Tank Removed- .. <br />....................... * ...............................................0.....•.. •.......................... <br />SECTION 3 - Tube filled out by contractor "decontaminating tank". <br />Tank Decontarntnatlon Contractor$ -t cc-L—Tz. v r CE. <br />AddressYC d' ... IC) i i.V 2r City$ c kr.vJZ1p:4S -'s;Z <br />Phone 1: <br />Authorized ropresrnuuve of contractor cenitying through signafUrc below that the tank bgm. d�contatniAated in as approved <br />marmer as required by Cal EPA. j p <br />NEW:/V f a� .:►il'_'s Title r. J r .Signam l j J�� tg.g Dau <br />...••ai a. N..N t.♦ H...•.p.1.1•. rN.11+.,.. uNM.. •... up.w.. ••. ut+tar•gg1.w«........ltttt. Y.N.... <br />VECTION 1 To be signed and dated by ant authorized representative of the treatment. storage. Of dispmai taeiliry <br />xctptingtank and/or piping_ <br />Facility NamlA7'i'�" C—tr�r►5) C�ItX.C1r=11,M:-y f <br />! tf r ter' " <br />Addrea: r%l'G' /amuCy . ��^^4Gam. Utt7 Ciry Z �t - Zip! <br />%'c' `� <br />Phone /• ()_ if %'.T'%G? <br />Date Tank ecetved.—— <br />]� Nom; _ it le �.t4.�= Signarurt: /� l-P/"'y Date <br />r` •.r•ra.r......r.. •....+..r.r..Ire.. •..r•........••..*..r..... •....err..••r••rr.rrrrrr.rarassr.rssr•.•r••• <br />EH 27 046 (Revised 9/11/96) Page 10 <br />'i. <br />TOTAL P.03 <br />