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General Engineering Connc: lc` <br />ENVIRONMENTAL <br />ENVIRONMENTAL HEALTH SERVICES UEPAR4, <br />.M1:N'. <br />Facility Name: S wee,, F O -AA /'I Q County Permit No.: <br />Address: ''.. /nCounty No.: 941--s— <br />�0 <br />++++ UNDERGROUND TANK DISPOSITION TRACKING RECORD +++++ <br />This form is to be returned to the County Environmental Health Services Department within 14 days of acceptance of the <br />tank(s) by an approved disposal or recycling facility. The holder of the permit with the number noted above is <br />responsible for insuring that this form is completed and returned. <br />ct i (To be filled out by tank removal contractor): <br />Tank Removal Contractor: <br />v <br />Address: n D b Odt S G 6 C) Telephone No.: C�-0 6 Y 00-6 <br />^" Zip Code: <br />Date Tanks <br />No. of Tank(s): I <br />e on j (To be filled out by contractor decontaminating tank(s)j: <br />Tank Decontamination Contractor:_ oOn.-�A - P PC <br />Address: Telephone No,: <br />Zip Code: <br />Tank Sim L,E L _ an ze <br />IOao �_ <br />Authorized representative of the contractor certifies by signing below that the tank(s) have been decontaminated it <br />accordance with County Environmental Health Services Department requirements. <br />io 1 (To be filled out rrd signed by an authorized representative of N approved disposal or recycling facility accepting <br />the tank(s)): <br />Facility Name:.. <br />Address: :5 o C&-aiLw,.T Telephone No.: e10'? )33 3,;L l <br />+ J? AIX. Zip Code: 9 :� 7aL.5 / <br />Date Tank(s) Received: A / 3 Z44V No, of Tanks: <br />Signature:_.�.a O�a� <br />Title:/ <br />P.O. Box 5660 • Fresno, CA 93755 <br />Phone (209) 233.2000 • Fax (209; 233-2066 <br />