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VG/1L Gvvx i`t is , as ---- .--- <br /> ... u.,.. .�. Gx ren nlaeaeluil '1'A1'1: ENVIRONMENTAL 006 <br /> FEB-32-04 17:80 FROM-KLEEMAN ROES N 010-038-1189 T-748 P.14/17 F-630 <br /> SAN JOAMN COUNTY PUBLIC 13EALTH SERVICES <br /> ENVIRONMMTAL HEALTH DIVISION <br /> UNDERGROLIND STOR4GZ TANK DISPOSITION TRACKING XXCORD <br /> f..w..w...}wrwWaWf.w Tw.wwwwr..}TY...•wwwwrww1Fwww.www.wwwww#wwwwwwwwiswrewwlMM4RwwwwwfaRAl�Mww4w}N.Yw <br /> SECTION 1.Public Health Services EnVlrOomeotal Health Diviaipn Teak Tracking Sheet shall ascompauy each:taluk.!'thea with <br /> Irs site Identification ngmber. The Tank Tracking Sheet Is to lit:retpmed to Public Health Services Environtnrnial Health Division <br /> within 30 dovs of acceptance of who tank by the disposal or mryeling facility. Thr permit holder is responsible for ensuring that <br /> this form is complrned and returned. <br /> FACILITY NAME: S,BG �la rl�lG/c- :P+ELG. <br /> FACILITY ADDRESS. 7/, yY Al. AS h Icy /_a0'r C , -5,47Gte 716 n CA <br /> TANK tD q3B- TANK SIZE: ZOGO PREV iOUS TANK CONTENTS: 10 <br /> www.nl.rrrwr.wTa,ezww.wwrwww}wwwT4.rTTM/wvwyTw.Tkwwrl,Awrfiawsa�rswiwwwwT'wnwwwlwewrwwr/w}rlwwlrw.wwrrr.wrrwY.wr• <br /> SECTION 2-To be filled out by tank rein"contractor: <br /> Tha Removal Contractor: //r/ 2!SV 9)1RQAJ ---rA-L. <br /> I /f <br /> Add, s //c;M_Oo� 1/£— Ciry: A� I/!4— Zip: g5 7 <br /> Phone f1' ( 41) p ST�0�_Date Tank Removed: <br /> .}e}..w.......f....y#r#.iw•T#Iw.wi.#•y...r.r.r.#i..ww#iiiT.yi-f.wTT.i.#i.y#.T.T..fw#ir..#•Trr.T............ <br /> SECTION 3-To be filled out by contractor"deeoutaminatin1l rank"/:7 <br /> Tank Decontamination Coatracmr: CO D <br /> Address: t��5 f�.l�r �d City: %G`/Moy�zip: `3 Yea <br /> i Authorized representative Of contractor cenlWag thmtult signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA, <br /> Name: Title Signature: Data <br /> ...w.Y.ro?...w.---..Y...ov.rvpo.}f..•'w#.yR wwTwwwwwgwpgpPwr.q#i#f.PT..4Tr.fiwa..br.rr..pr <br /> SECTION 4•To be signed aqd dared by an nuehbrlaed repreaentadve of tho traetmeni,storage, or disposal facility <br /> i <br /> accepting tank and/or piping. <br /> Futility <br /> Name: <br /> ame: S�*r <br /> CIH: /GAdde : yS�f� <br /> s <br /> Phoneb: (_5/0 ) /3 /n3 <br /> Dare Tari:Received: <br /> Name: Tide: Signature: Date <br /> W.Tr.rlW.a.rTlw.witYlMTT..........w... .......................... taw.}y1wY................M..TwR..TTw�#fw <br /> EH 73 046 (Revised OS/13/98) Page 10 <br /> 02/10/04 TUR 10:26 [TX/RX NO 68811 006 <br /> 3001n I V H MVHS 670ZLZ9GZ6T XVA 6Z:ET HRS. b0/0T/Z0 <br /> RECEIVED FEB-11-04 15:09 FROM-9168581011 TO-KLEEMAN ROEBBELEN PAGE 12 <br />