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---- <br /> 4-PI l i-F <br /> N. 1 <br /> \r \I <br /> sAll JOAQLTN cowry nBL:C HEALTH sERvicu <br /> LNVTRONMWrAL HEALTH XMION <br /> 1� LNVERGROL^lll STORAGE TANK DGSPOSMON TRACI.7NG RECORD <br /> .......... <br /> .........r.._..__..>.....>rra...r...r.r.....>--- <br /> .>.a....a.>......,�----------- <br /> ..--------- <br /> PPP sEC'.ION 1 - PuOtIc Hrlta sc.vies Earimamencti 3r..[th Division'sok':aekiag 41=sdaif secot�aaf ests3 tank:Ni�eC <br /> aim its site '.denrflratioa cumber. The Tann Tacking She?s ra be:emmed m pcbiic Realty Se^i;¢s ?�vimnmccat t?c�itb <br /> Division ivit6in 30 days a( scxbmace o(the yak by the disposal or tee/c:sg�ai7iry The permit!wlder is rescomible Cor <br /> ==ng:hat this form is eompieted a= ;ttaroed. <br /> rn�f.�LS�yv <br /> FACD.."�Y ADDR9s5: 7Se7 tv Nth Sr e,^^r -- — <br /> W* /3!Zai -- — <br /> T,A;I SC fD A39- 640*101P? TANK StM, /di d7L PREVIOUS TANK CON M.N -5 <br /> ...................................... <br /> >..,r..>.».......�..>....�...............>......_....._..._... <br /> SECTION 2 -Ta be fMtd aut by Sank removal soarraiaor: <br /> Tank Reiroval Conr avar. <br /> Aemross: 6 cs/? r I - Car ., Z,F: 9 i 3 74 <br /> .1 f 2- - t 0 Dam rank Removed: �— <br /> .r....»ru......«........r_.....w_. ..w.........se..........I....«....r...r....».............r......... <br /> SEC 1ON 3 -'.o be armed nuc ti rnntradtor "decoaraminating*auk": <br /> ' <br /> Tank De-antamiasdon Coatracrar: <br /> Addrea: F614Jh City: / Zip: 1�•�7�0 <br /> �mboe'ized rep:t:searstivo o(canamesor�ri`'rag?btuug� �t:aNra ha[ow ,*„�e btak has bene Csratatywta; a:at apgmved <br /> awaer ss xquiren by Cal EPA- <br /> Name: Title: Signanue: Due_— <br /> ............ .................. <br /> ue.......r....•rf>..vrr.wr.vr.es...a>ra.,.>................... ................ <br /> SECTSON a .To be stg..ed tad dated by m authartzed repmentadve of The¢eatmea:. ronwZe. or stsposai fre:iin <br /> ac."9 itt`rink card--or piping <br /> // <br /> :2ciliry dame: <br /> Address: 3 /�rWV QCv�. City: te'`-'+��"�"� Zip. <br /> Ptame,t: ZZ <br /> Due Tsnk 3accivcd: _ <br /> UM: Title: 4lgaan:cc: nye <br /> ... ... . . ......o...........__.------- <br /> PFI '_3 3,16 (Revised 3/i`.l96) Page to <br />