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f � < <br /> THERE WILL BE THREE (3) <br /> FORMS, ONE FOR EACH TANK. I• <br /> yr <br /> UAiDERGRO[JND STORAGE TANK DISPOSCC[ON 'CRACKING RF,CORD <br /> uau. u•••t'••r•rtt>••ttt••rtt•t•••¢••u•¢tttr>•u•••••t t+•tutr••u•t•t• <br /> mpany each tank <br /> ed with <br /> dentification <br /> numbe <br /> l acco <br /> t <br /> SEC ITOIIjI; Pub�tllc�HtPg m t Public Health-vices Tracldng Sheet Services within 30 days of aucceptan tLof ttha tank by he disposalror <br /> �,Tit pergtft Holder Is responsible for ensuring that this form is completed and returned. <br /> r <br /> r � ,r= ti yr t•�1� .� '. <br /> CUS `RV -- <br /> 1 1ACrL1TYrNAME <br /> 4807 <br /> S. AIRPORT WAY, STOCKTON, CA 95206 — <br /> i:-IiY ADDRFSS: <br /> 39 /.5-ldTan kDescription: y2l p�g^ l �"�"" 1, 1,000 gai <br /> q >[cs¢rttt/ttfttOHltttltYHtttttt Y•ttttttftttt tit Rtt.tttt>f••tf'¢»»•»>•!•t•tt Rt tUt r>•rt•twtr•••rt[>v.•• <br /> SECCION 2 -T4 be filled out by tank removal contractor: <br /> i:. Tank Removal Contractor. WESTERN METER SERVICE, INC. <br /> STOCKTON 95205 <br /> . 2735 .TEEPEE DR- P STE. E City: tip: <br /> [ Addresss: <br /> n209 948-6124 Date Tank Removed: <br /> — - - _ <br /> rt =;t.. ttf "� ftt1 sltt9lttt�f ttttttNttlHt�ttttf•♦t•nst••t••trttlt•rus•••Nrt••tt••t••H•R•rt••utru•r <br /> 77— <br /> ggCTION 3 To be filled out by contractor'decontaminatingtank': <br /> REFER: SECTION 2, ABOVE <br /> �. Tank Decontamination Contractor. --- <br /> ` - - <br /> City._____ __— — Zip._------ <br /> > hope#:.( ) — <br /> Aithoriaed representative of contractor"certifying through signature beloW that the tank has been dccontaminated in sn <br /> ,.approved manner as required by Cal.EPA- <br /> Title: S1LES MGR. <br /> Signature:� t <br /> •>•r[e>fs... <br /> ar>•a ttHHt• itl it it tlt•ti[\tttttftttr t•..•t•r•••••t•»•»1'!•!d•!•••!•t•>1t H•t!•H••tt t> [>>> <br /> SECITO-N d - To be signed and dated by an authorized representative of the trcatmcnt storage; or disposal facility <br /> accepting tank and/or piping. <br /> Fact7ity'Namee CAL-COAST MFG. CO <br /> TURLOCK 95380 <br /> Flo T'.;hl ti City Zip: <br /> Address: <br /> 7.09 668-9378 <br /> .Phone #: ( ) �} <br /> 7 <br /> DsteTan <br /> kR - "i <br /> f r <br /> - s -----------Title: _ --- <br /> Signatuie ---- - -- - -- <br /> rr-^ <br /> i <br /> »¢1¢•twttYtt9t YtttttttttlOffOtt}tttt•trtrtttt!••0•¢>>[!>a!>t>a¢Ff.ief>•t•»tf>t•••>•>••»•••••vt••t•f>tt <br /> . . PRa« to <br /> „I - EX 23 GS9_ (Revised 7-10.92) . <br />