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12/03/2003 13:10 2094671118 <br />AGE STOCKTON <br />SAN dOAQULN COUNTY PUBLIC HEALTH SERVICES <br />ENVIROrNNIENTAL HEALTH Dr,7SION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACIaNG RECORD <br />PAGE 08/09 <br />w•rtwprrrrr•rt•#nrt#wYrrtrralasarrrwrww>aaaaawwwwaaaawwwwwwaaaaawww:•#wwwww+r#awr•rt#•#Yr•r•rtrtYrtwrr#•rtY#ar+rtwww <br />SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany eskh'tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 &Lss of acceptance of the tank by the disposal or recycling faciliry. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: �t¢,� <br />/�cP�t.�..`"+O- ca <br />FACILITY ADDRESS: `q` A�0 4,�-- �rI VT'h <br />TANK ID #39 - `L_TANK SIZE: pREVIOUS TANK CO ENTS: y� <br />taswwrlr+rarrr+##rtaa>rrriwwwYwrtwas!#•WWrYalwwY##w+rwwrwwNrtrtwawa#wrtwwY##rrtrtlri•rYYwY>lrrYrw>••"'wrtrtww#rtww##YW <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:_ VeA� CinR `On�r i <br />Address: DO Q( ��,�/!� ``�S <br />City:` Z�'--'d <br />Phone N: (�(�) jp LI '"� b f -Date Tank Removed. <br />w#wwrrtrtwaawrrtrw##warlwwrtrt##awrrrtw#www#rrtYa*•rYrwwYYrfrw•rtrYwwf#;rYrrtwwrtwwlrrwwrtrrrt•r#wawrtrtYawwrtYYwrr#YYYwwrt <br />SECTION 3 - To be filled out by contractor "decantaminating tank": <br />Talc DCCOutaminatiOn Contractor: -4 --me" tav, Valle, G-) <br />Address: Y h c(. b <br />Zi <br />P R 5 31 s..�. <br />Phone (010) U in 0 C <br />Authorized representative of contractor certifying through signature below mat the tank has been decomamfnated in an approves{ <br />manner as required by Cl EPA. <br />W6"kName:�or Title: <br />to Si a <br />SECTION 4 - To be signed and dated by an authorized re Yww+##warrrYrYr►#rwa+>rtr <br />accepting tank.and/or piping. representative of the treatment, storage, or disposal facility <br />Facility Name: LjeSF <br />Amu: L, City:7vCIOc.t-7�L <br />Phone N: (_Inn) (a (n * J — q,),-7 7 ` z�' —6 2 _ _ <br />(Revised 08/13/99) <br />