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5-03-1999 2: 16PM FROM P. 13 <br /> SAN JOAQUIN COUNTY PUBLIC EWALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> W prrrrrrrrWWwrUrw4rrrwwrprwwr........WWWIr,FrLpWWfpplitarl.......... W4Wr.�WIWWWwr Wrrkrflrr Wr.Yrr14 Wr <br /> SECTION 1 - Public Health Services EavironrnenW Health Division Tank Tracking Sheet shall accompany each tante affixed with <br /> its site identification number. The Tank Tracking Sheet is w be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for miring that <br /> this fort is completed and returned. <br /> FACIIITY NAME: <br /> FACILITY ADDRESS: X47 !) L1l.J <br /> TANK ID#39 - PALM TANK SIZE: 515b PREVIOUS TANK CONTENTS: kS41� <br /> rrrpwrwr..WWW pprpp..... WWM1WrylrpprWWWrprMWppwpr.Wawpwprrrpprpr.......rwWMwrrrrrrWprrrWWWr <br /> SECTION 2 -To be filled out by <br /> tank removal contractor- <br /> Tank <br /> ' G <br /> Tank Removal Contraewr:�L f l^�`'-'SIV �T r-A-A L(-At " '�Q P f C T <br /> Address: �(�l tit�0-1—A05 �y Q` City: ��sa t-tslgtlgt; Zip' <br /> 35361 <br /> Phone x: ( > b`T I b 51 Date Tads Removed: 5 <br /> rr........arrrrwwrrrrwrrppaarprrrwsawrprrrpwrrrrrrrrrpppapwpswprpswrswwrr.psraarrrrprpr.. <br /> SECTION 3 -To be filled out by courr�actor"decontaminating tank": <br /> Tank Decontamination Contractor: W l ( ez-rw � , <br /> Address. 6U04E zip: JJbl <br /> Phone x: ( n] <br /> Authorized representative of contractor certifying through signature below that the tank bas been decontaminated in an approved <br /> manner as required by Cal C�EPA. ,t � � ,, � �,� <br /> Name �� at+'� Title: l TiY /t�� Sigttattce: Date .6 I r I_ a_ <br /> WpirwrrprrrwrrrwrrrrrrrwrrW......0WpwrrraarWlp\WWWWMpMIF4111rrWrillWrWYpr ppiwrYrrwrpprrrpprr-- <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment. swrage, or disposal facility <br /> accepting umk and/or Piping. <br /> jC e <br /> Facility Name:_ '�' JV�t�S <br /> Address: 16i6 A-P&E .a LAM Ciry:tM OM) zip: <br /> Phone#: ( , 537 <br /> Date Tank Received: 'p 6 <br /> -1 <br /> Name: �1WrwR+tSt t,�L� ride:t \C TL ILS;gnature: <br /> W W W wW W rtes.wva.M prpprrrrWvsorprrparaYrrwrrprrrr.........rrrrrrWrrw rr p....... i.rraYw <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />