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.. �.....� ..r.�co a env ee.0 •l625G P 03 <br /> SAN JOAQM COUNTY PUBLIC HEALTH SERVICES <br /> F,NVIRONhf MAL EMALTH DrMION <br /> UNDYRGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> xYlaiwiaf 41aa44}\ir#ii;i;i;4aii Ra+Rwftflf;VRR4;4#;a;;4#4;MVywwaw4V;a1#;1;;taa}Vw4Q4YVVW4V i4wx44Y4 wt+V.rti xx+ <br /> SECTION 1 - Public Health Services Envirou rnental Health Division Tank Tracking Sheet shall accompany each tank affixed s,:v: <br /> its site Identification number. The Tank Ttacking Sheet is to be returned to Public Health Services Environmental Health Divisinr, <br /> w"ID 30 43 of acceptance of the tank by the disposal or recycling facility. The perralt holder is responsible for ensuring Oat <br /> this form is completed and returned. <br /> FACILITY NAME: �ltn�Qhs Q��l>1� <br /> FACILITY ADDRESS: 2 ?�• _� >ST �R f'tTtu ni- S rq e -- <br /> TANK iD#39- --_---TANK SIZE: 7pMye,. CACs/I/.r� PREVIOUS TANK <br /> — ».s»rr#rtf aiiwaraiay.itrriaaeaffflfrlsf♦;wRttaks#f#ai}ayyi4yry MW\i;rtakiwkkaf#;;VaM;Vtw+4aawsr»V twar...+;nR++ <br /> SECTION 2 - To be filled out 1by tank removal eontn ct^^or: <br /> Tank Removal Contractor: <br /> Address:_yD°��lt[tA?t���M1�: )Srrn Wn `f /City: STQekinei zip: 5 lr6............... <br /> phone 0! (20G 1_u "� _I 9 S�i D 4 Date Tank Removed: C+rrn Q t0, <br /> +r»aaa+»4a}f rwwaaVrylvarr YVVVY,4#tra#aaaaa;V VwWyal;4iaaa:;ayk;4A}}iYity;y;;;;w;;rf;+a;w}ai4i+++www.J;+rxr Yrr J+ <br /> SECTION 3 • To be filled out by contractor "decontamina <br /> ^ting tank": <br /> Tank Decontamination Contracror:�AW_( � lit FnvSQ�rllPn�t1I �ltC • ____� <br /> AdameS: _qo5 ...-liJoFiTH---�-L�tlSc _L1L —��City:- STot Ton__Zip:-- g��8-- <br /> Pbone U (Its tL•) 46 7--100 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated m an appro,ed <br /> :natu;cr as rtquir�ed-•by Cal EPA. r I G �j <br /> Name: M C C��—�T1de:�0aee7 Gpltisj Signature: <br /> ix»a#.trtta a4W4k};»ai♦rV+»44Vrf Vliraaf Vi;!lova;;tarts+rtaa#at##4a}Y#;wVw#w4iywy44aaaf fffiaafif;lw4#4}wWr���.. <br /> SECTION 4 -To be signed and dated by an authorized repretentative of the treatment, storage, or disposal facility <br /> acccp6og tank and/or piping. <br /> Facility Natnc:�/1/ I1� •$�1' 1 p�4v, I�,�N 1 _95 <br /> PhoneAddress:_ SL_�!'�GJ( 9,376G�CO Cary:_Zip: _.._!-J <br /> Phone#: ( 0� ) 0. T v <br /> Date Tank <br /> eceived:_ ¢ - <br /> 1t1e: Signa Fate-- <br /> .aawlviasaswr;..;aa;fwal;raiyitayasa.aa4a Visa##;;a#aswyaaalr#}A#y4},FM44+waas;asaar;wnn M1l;w#+asMrai»vaaa aw <br /> FH 73 046 (Revised 10119/98) Page 10 <br />