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SAN B)MI1N comrV Pl1nuc DIrALTII SIr,RVIG'tEgl <br /> RNVIRt1NWNTAL IIBALTII DIVISION <br /> VNIIRRGROUND STORAGE TANK DISPOSITION 11tACKMO RECORD <br /> r <br /> 64♦/u..♦♦♦H♦H♦♦•+HH♦•►H►HH♦Hrr♦♦♦H♦Hr♦rr♦•♦rrH♦►H►H♦►►1►►aM1►aNN1N1111►11H1111111H111 <br /> Ar.f't1Ur1 I - Pohllr. 1Ie6111t Servlrel Pnvhonnrrntnl NcARh Division Took Trsrklog %eel shell lceemp111y each h1Mk 11111ted <br /> Milo IIs Or IJrotlllcndnn nunlher. 1110 rank 1lnrking Sher) le In Ire remmo0d to Puhlle Ilesllh Services Lnvirtmimmlid NNIIh <br /> Itivinbnl nllhln JO ifim or errepinnr0 or die Innk by file disposal nr reryrling rsCllily. The petmll holder b tespnellms ke <br /> em oleo I1n1 lids form Is Completed end telorned, <br /> I'ACII AIV NAMp:Lincoln Unified Maintainence Yarn! 15.1'.A. I1NM CAL 000049384 <br /> 1'M IIJIV AhIMP.9.0: 6749 Harrisburg Place. Stockton. CA 95207 <br /> IANK ID A11 1ANK SIM 10,000 9a110pRRVI0US TANK CONTENTS: diesel fuel <br /> lu•,.•rr♦•a••aH♦♦••♦H♦•H♦•H♦r♦•♦♦♦H•H♦Har►♦♦N♦H♦•♦rHHH♦H♦rr►►►►►►►•H1NNN1•N/1N111MNN <br /> O'C lION t - to be tilled out by Innk ternnrnl cnnllaclor: i <br /> lnmk Removal Contlertor Jlnl TII01'pc oil, LIC — <br /> Addtetr: 35_I- N, Heckman Nd./V-U. Box J51 city: Lodi, CA zip; 85241-oJ57._ <br /> rhonr. ►; ( 209 _)_J60-6_15 _ Date Tsnk Removed: j <br /> 1 ru,r r•I••r•♦♦♦♦H♦•♦♦11NH•N••♦♦♦H•M♦IN••HH♦♦♦♦NNH♦r♦r►rrlf►H►►1♦1►►►►H�111.11/1111111111E111 <br /> 5RC1ION 1 - to he tilled not by ronitnclnr "decnnlsmin111nA Innk": <br /> Innk heroomnlnafion Conueclor: JJ.nI '11101pe 0111 lac. 6 <br /> Lodi CA _ <br /> Adfirsc JSI II. Uedanan Ild./I'.U. Uox 357 Chy: r Zip:15241-0357 <br /> Moor, A: (-.209---I 36U=61'x5 <br /> Amfi,vil d Irprrnrnlallve or comnclor cellirylog i mmlgh signature below lion the Isnk has been decoumminNed In W IlWrnYed <br /> nunmer as Irilolml by Cal EPA. <br /> Ilour Hite: Signelute: <br /> , <br /> . ,♦ ,s, ♦ a.r► ♦a, ♦ •♦ ► ♦HH . • H•+H ♦♦►Hr ♦♦♦ ♦ ry♦H • ve ♦• I�• 11M1��1FF1N 1N1111 <br /> alit i s (rhe of ga rt1pJ �hy an11�c1�oar„ion vajlvrst 11�)on Je��ve goo ��Ibtip� f cIIIHeeT r j <br /> SRI' IUN 4 -it be sl netl and dal an Rnl wt :e re resenll Ire of l e Ireslmenl, 11141 <br /> 1 1 <br /> Acrepdng lank And/or plplog. I , <br /> rmllhyflmne SCInlltzcl .^,feel I' ----- cl.s I <br /> IZUUU ro1901n 111yd. Hnncho Cor•dovat CA <br /> Adrheer 1200_ _ — _ — city: Zlpr 95742 <br /> Phone A ( 116 1 9115--111110 <br /> Dale Imrk Recrlved:—— - 1212-- ��- <br /> Hnme: I1tle: Slgnslure: Due <br /> rN1•,/♦•♦•♦••.••HHH•+HH••H•••♦HHH•HHrr♦r♦H•rHrH♦Hr♦H•♦♦♦►♦NNNNMNN111NN111111111 . i' <br /> ' I <br /> 1'il 2l O1G (Itcvleed 9/11/9f1) Page 10 <br /> j � <br />