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f . <br /> SAN dOAQULN, COUNTY PUBLIC EEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I- Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site ideutificatian number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> withiu 30 days of acceptance of the tank by the disposal or recycling faciIity- The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: C Oar er)--e r Go , <br /> FACILITY ADDRESS: 2 ()v 1t-O Cc GSC <br /> TANK ID#39- TANK SIZE: f�,�Od PREVIOUS TANK CONTENTS: 17 r e S e, <br /> *:r�**r**s»*****•*********�**r�r**rr******�,w�rr�r�**err*r�*�*******r******�*��**ter*rw�*»***sem*�***s*****�+w . <br /> SECTION 2-To be filled out by tank rem{o}val contractor: <br /> 'Tank Removal Contractor: - A U e.Gt E n A t n ee r (A� <br /> -V- <br /> S <br /> Address: I (PS9 - Lucerne- Ave City: S+oc.k4O1 zip: 9520 3 <br /> Phone#:(.20 9 ) Y&`/-atm 1y Date Tank Removed: <br /> SECTION 3-To be tilled out by contractor'"decontaminating tank": <br /> Tank Decontaminatigan Contractor: V Q k U p- en1 j neer, y\4. <br /> Address: Jr/ ___L U G 2 r'r1 C f u e, _ City:_ S k4-o,, zip: gsa c 3 <br /> Phone#:(a 0'i ) ` - o <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: JCLrri2.IN L.Ct-l),e1[ Title:CL,r)L Signature: � Date 0,3 <br /> �rr�r*sr**r**�****s�*sr*rr*+r�*r�..a.**��.*�**w�.s+r«*�r��r**�r,�M*r*�«* ***,*rs��+h***��rr�**�*shr�r�w****r*xr�► <br /> SZ=CK 4-To be gad dated by an Audbarhtd Y*pnmmwdhv of d)z uwmi*gac.sorsm ori flrahiey <br /> Xu ptiag tankANIftt 9WAS. <br /> 1;MmtyNawar: as+ 4 fuigment. ... <br /> LFA ay_t Car -r�10 K- Z% q iso. <br /> Oft Tet Rec:ehgA 3 i4 9^ <br /> �-~ <br /> ■st*YuYrM«wrra w�rtM+i#rss�yrNrrR**�nr*sN0 06rs04Y0 +014104 NMM <br /> LH 23 W6 (>�en►ls+d 0l1/23/9q) p,�e tp - <br />