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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORI) <br /> ..........•r•••s.a.•r•••aaaaaaaaNM►l►►►aNalaaaaab►►►1b►►►ll►►l►►►a►►l►►►►►►►►►►►►aaaaabaaaaa.••...... <br /> cr( rION I - Public Health Services Environmental Health blvlaled Tarok 'Tacking Sheet shall aceotmpany each lank amsed <br /> h ;,s like identification number. The Tank Tracking Sheet Is Io be Whittled to Pllblle Walth Setvices Environmental Hearth <br /> r a•;<;on withinJ0 da" of acceptance of the tank by the disposal of recyeling facility. The panni! holder Is responsible for <br /> „"n,;nr that this form is completed and returned. II <br /> r�r'll.t[Y NAME:_ A%,N LO Y 1 fn1A7LV�IMbLC(!- <br /> I N( II 1F ADDRESS:- , <br /> I VIV II) 939 •IS�{( TANK SIZE: . r�C"jr_PREVIOUS TANK CONtMTS: <br /> ..........•♦•r•a•♦•••♦NN4HaHla►alai Naa4aNaaaaaaaaaaaaaaaaa44a MaNMaaaaaa aaaaaa4a••4a Naa4H•••••... <br /> I( I?ON 2 . To he rifled out byfemoral moral contractor: I <br /> r."t Pnnoval Con(ractur:_SIC 1hL- S[lln V,N- �lL IAV,1_ C)I LL�c <br /> 7X-7ft� City: Zip: ` <(n�4--- <br /> r4„r.• 9: ( 93Q f. bate tank Removed: .401-30 - <br /> ..........u•w•••4a••a�••rr4all/a♦alNal/4aaalaalaalallali►aalalaaaaaN►44a►►a►►aaaa4raaaaNaa••aNaaa••.. . <br /> �zF CI ION 3 - To be filled out by contractor "decontaminating lank"i <br /> I-nd urcunian l mtlon Conlractor:3 ,.1 lt�i •Yf z t �l tz} 1�A.a ('�Pll•1�T t`L�'t Intn �_ •� <br /> t 0 J,�,-,>L -, 1./�ra 9 City: 12�( wi-N Zip: <br /> I•h•,or 9: r Ste)—uZg2�1�3Z��-� --------- <br /> \•„horised representative of cowtoctot t iriltyimg lhtough llgnstute belda (hal the lank h9.1 beed decontaminated In an approved <br /> never as required by Cal EPA. I <br /> I <br /> •,,,•^ �r . .��61,,,�ae;: <br /> Title: �ordly 9lgnamte• t bele 12 -i~Sd—y� <br /> .......•.•u•.aaa aNlllaaM►N►HIIIM►►I►l►al►a►l►►Nll►►laaM991iaaaaia►9l4aiaa9aaia►lanaaU♦►aMaaaaa4•.r <br /> 4 - To be signed and dated by im amthditaed tepteft dilye at the tteatmenl, atotage, of disposal facility <br /> accepting tank and/or piping. <br /> c n,I V-A" <br /> 1 i•';inv Nate: �(� (IA ��L� c- <br /> A—LJ6 Cityl zip! <br /> I <br /> 1)a,, 'lank <br /> Received: ® '. 9 <br /> •) A/ V ,rew/STitle:�fC�Sr _91gfflAm� Dote 4-3 0 <br /> ........•.•••.•r.aaaalaaNlallalbllH•aalllla►alMll►►►l►►►►►1►►l/al►a►►►►►►ll►►la►aaaaalaaMllaaaaaaa•• <br /> 1 n • 0iii fRevised 9111/96) Page 10 <br />