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it <br /> THERE WILL BE THREE (3) FORMS, ONE FOR EACHTANK. <br /> UNDERGROUND STORAGE TANK DISPOSITIONTRACK]NG RECORD <br /> i <br /> 1.�i+++++aY •itN t+�H1+tatt tri+rya+it+++tY++t++ta++Hrtatt+++HJb+J+++++tt J++++Jei+++t++Jttt+H identification <br /> number. ' <br /> the disposal or <br /> Thee rraOcktng SheetcLHealth s to be eturrtd to Public Health Services wracking Sheet will accOm,ithin 30 days of affixed <br /> aceto[thelaanlciby(tion nu r. <br /> rrryding f&tillty. The permit holder Is responsible for ensuring that this form is completed and return <br /> CUSTOM RV <br /> FArICfI1R°NAME: 95206 <br /> 4807 S. AIRPORT WAY, STOCKTON, CA <br /> ,-;LITY.AD DRES°,:_ <br /> i ' —1, 1,000 gal <br /> 3 Tank Description: <br /> 39 - m--- <br /> �a t 1 �H!!l1Nja{t♦lltu HtaataH tit+aattu tytrtiva�uu ututHu•lt ttauututaN <br /> nk'"rtimovaI contractor. <br /> Contractor . WESTERN METER SERVICE, INC. 95205 <br /> STOCKTON , Zip: <br /> 35 TEEPEE 1)$..,,_ STE. E City: � <br /> 2 J�) <br /> 948-6124 Date Tank Removed: <br /> ad!l Yaia YY iV ua.98tato+uut•t+rtuuu�taOftttttuuttpu+taiiHuruiutt utt attHututi• <br /> i <br /> J 'I'o he n11ed out by Contractor 'decontaminating tank': REFER: SECTION 2, ABOVE <br /> T k I�Ccoptaminatiun Contractor. - <br /> City:_- - 7jp. <br /> y' A .irec�r I <br /> == Ar.hori i representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> ;'approved manner as'required by Cal EPA. <br /> Tide: SALES MGR• <br /> S mature: i <br /> ssa++RaaV+J aY Jtit J9J a0Ft+t0+9a1t++HOt++JtttiF+fta++t9+i9J+++++r++t J+t++IN IJ to r•++tat+a+++oaf t++tt+t+++ <br /> t, storage, or dispoW ;ac;lityl Y' <br /> 17CTION S To be sighed and,dated by an authorized re, <br /> prestntative of the treatment, I. <br /> accepting tank and/or piping. <br /> CAL-COAST MFG. CO <br /> ality_Name, _ 95380 <br /> "�— TURLOCK Zi <br /> .242-TAQIAB-ROAR [�� S , _City: p' <br /> ' Addrtss: <br /> n. <br /> ".rine n: 209 �_ 66879378 _ -- — - <br /> '0.,t Tani RccciVcd, -- <br /> ` - <br /> ": Signaturt- ,, _ --)act, -- - <br /> '+ ixJaYt6at+af at 90 t+Jit++a9aoR+aatt ........... <br /> Naatsa+++rJ+t a++t t 9.x J a•iao.=eeeles J+u+a++t+J J+J t.+J•+ ^)x. <br /> pare 10 <br /> r , Z3 Lt,9 (RevSaee 7-10-92) <br /> s <br />