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<-i yyo b-❑.t:�t1 r" .t 'r. 0 <br /> SAN SOAQETrK COUNTY PURUC HKALTH SMVICES <br /> r3'NVM0 cLN—r-kL MALT$DIVLSTON <br /> UNDERGROUND STORAGE TAYK DLSPCSTIION TSLiC.d1NG RECORD <br /> ...............r......,.,......e.......,,...................�.................»............a....................... <br /> SECTION 1 -?¢blie HCa!m 5e:+iez Emim==ai Heai:h Dir-sim Tmk Tracking Stat 36aa a�ampany eat rank arCuee <br /> witb IS sem itiecaccs[tor.attaber. Tne Tank rm=r Sheer:s to W :maned ro Pnotie Fieaith Services Eavironmeeral=emra <br /> Division wfthin 330 days 3t ;hc=kby he iisoosal o:.ejcdng iaci!ity- The permit bdder is sponsibic .`o: <br /> mst=%That this form is W=[e:ed/and rett.med. <br /> F.kC;L!TY NAME;__ j <br /> FAC. AI)C ESi_ <br /> TANK M f39 _TANK SIZE: ,F.1" PREVIOUS T4.`tK <br /> ......................amara./OaYas.«aa.aM........Y..aaavaV Vra.a.Yaaa.aa.aaq..a......i...... <br /> SECTION 2 -To be 51Ied out by ttaeh rodoval tonna ror <br /> Tack Rmaoval Cee ttzr. <br /> Address: 0 [�/7 se4 <br /> t� D, Crry: 1�`., Zip. r7l 76- <br /> Dace 7mt Removed: <br /> I.a..........MM...a.a..• Wp.a...a....wa...YaYa....r..a1r.Y.a..a«..sM.r......a awn.a.......Ya <br /> SECTION 3 -To be 51!ed out by cozu-actor 'demoramiottting mak": <br /> Tank Decoatarr.btadan Ccnn=or: 7j r tf a `ln Ia , <br /> Address: 0 4/7 �f-�,.•ew,y Do, �- cry: zp: <br /> Aurhor!Zcd:cpresentxi.e of w=rwtor=ifnag tl>_ ugt*mmre Sorrow h$he mr:be been dr_actammated in m approved <br /> sane-as required by Cal E?w. <br /> Yate: <br /> ......................a.........r....aw..».».Y..... _. ........----.........---.. .................... <br /> SECTION a - To be ugmd add tued by in aachoriaed represemmivt of rhe veai�- moiage. or disoasai Seility <br /> wAxtmn3 rank=Yor piping <br /> Fadli.-v Name: L y' <br /> Address. 't -s a ' O <br /> Daft T.mk l=ived; <br /> Yams Tier- Sig:tattsre: Da¢ <br /> r....................a.....«....a.......Y.....«..Y....a..aa.....Y....Y...a...a.aaa..Ya. <br /> EH = 046 IRavtaed 911:196) Net :0 <br />