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P. 5 <br /> SAN JOAQLaN COUNTY MIREIC FtF.kLTH SERV jCZS <br /> LNVMONK VTAL WALTH DLVIMGN <br /> L'NDEHGROI.'ND STORAGE T v(X DLSPOSLTLON'I ACXNG RECORD <br /> r..+.a.......u..........a....w......r...w..-r..»...r...+...r........-...r+w»...r.....�w..rw....._.. <br /> S'1•'CTZQI`I 1 • y�tiOltG eEealm SE^!iC_{ Y',tnpt@IItlj ilil�i3 �1ri510II LOk �CKking 7=a 3 iGN= y =ch L1p�t SL}IECd <br /> with is ata ideanf ertian❑tanner. The Taek Tra=q Sbeet Ism be Tm rocd to Ptotic health Services ravtron=nmI Reith <br /> Divisi0a within 30 chug at a -Pp of rhe nak by U dismsa!or ree/c:iag`a:.Iiry. The p rntk holder u rmmous"e;or <br /> =smmg that Ills forma coogfered amd temrncd. <br /> FAC=. NAME:_ AJ/A <br /> F.4CnXrY .4bDR£SS: L,: N y R. S7- CA <br /> asp 6 z a — ' Ar <br /> TA14K ID 639 - TTNK SIZc: �Cl re PRs 'lUt 3 T-arX CO v7E`l:S: Oma• <br /> .....Ii.M.w.M1.Y1a.a.iafaY.p.l..va.Y....r..a.aAfYaMr.aHlY.r...vl.Mitll.rfw.a a...f...NaY.+!aaa <br /> SECTION 2 -To be tilled Out by [salt rmtowsl eootmcror. <br /> Tack RexwdpC�/oattaecorL. <br /> Address:_ p e,�17 Gt�ir+w+r �°� Car. �.ty� 2na i 3 7& <br /> i� <br /> PlOec I.: '.z.�` ; �� Z —� pate Tack licaored: <br /> s..............rw.ra..r..r......oaa............r...ws..................r...............r...........r.. <br /> SEC TION 3 .i0 be Bled ma Sy emmadw 'dcraatataioadug tank['' <br /> Tank Demmizatrihmou Coc=nror: L/, ` i .L<./z✓_ <br /> Adds.: dfad 7O G�K+•✓"'^a Ab- 1�,..�,..r-y_ zip: <br /> .h"oezet.-epreseatative of aaax:or crifying dstvogh 31-,M=t:claw;Sat die aok sus berg dteocamivaeed iA m ap;rsved <br /> -,..,..er as :muired by Cat L2A- <br /> Vane: Titk: .__..___•__Slgaussa: -- ---_—. —Data - -- <br /> ..a....»rw...rwY.e...............r r...r....w....a..w..r...a.............w.....rw.a...a..........rr.. <br /> SECTIO[Y 4 - To be signed sad dated by =authorized represe Md.e of the_M=int_storage. or 3isposaf facility <br /> at:cepdnZ_t•,a-ic Ubdi�or piping. <br /> awf0 ' <br /> Ad;.ms: C ey: Lp: i <br /> Dam Tank Rcamrmd: <br /> Naac• T:de: Sigvmtm Dale <br /> a..n.w...Y...........VYw......v .r.......a......uyaw..r.........s.....wa..aw.wasys.+w..ws <br /> 3-1 a 046 IRNised 91L1j96) Fuge l0 <br />