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SEP 03 '97 09:34 USA PETROLEUM POMOMA 714 6221002 P <br /> SAN JOAQUIN COUNTY PUBLIC nFALTH SERVICES <br /> ENMONMENCAL IIF.ALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISP06MON TRACKW(q RECORD <br /> ##kY►►ii#FNYwYF►►#VWfd++►#w#kif+rt#N*inti#rt►wtriW#tki*ttww*r++*rt1fFWk#4k#wki+►iTffi#Wf 1+#►##Wrti►Y###rtfdiY►t#- <br /> SECTION I -.Public Health Services Envirowncistal Health Dtvisioa Tank Tracking Sheat shail accompany eaeb tankafiised <br /> with Its site identification camber, The Tank Tracking Sheet is to be returned to public Health services Enviroan=W Health <br /> Division RMIR 3o dare of aocephmae of the tank by the disposal ur recycling iitc(lity. The pet nit holder is responsible fat <br /> ensuring that this form is compkled and returned. <br /> FACILITY NAME � <br /> FACILITY ADDRESS: Q <br /> TANK lb d39 - "TANK SIZE: PREVIOUS TANK CONTENTS: <br /> 'flt. ti� <br /> #NP#kHwWWN++##►rtWk+YiwaW#r#i*wrtW+iwMf!#kkk+w#wrtM++it###Frikkp####kk*bt##rrMr►#RN#kkkrw#r#9rfk#rrik#+W i+ .. <br /> SECTION 3 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor;�($',t, <br /> Address: �2 b <br /> City' ZIP: 140-2kla <br /> Phone A: dQ3_1kU 31 t .. A— Date Tank Removed: -y <br /> ifir■t#44frwtifrtw#i►ti#f NWYip#W#**w#tw+N#I/i#WrrkwY#t#kw**YkwrtWrrriiWi#Atwwr+iYffwrdidwf w►##►#+#w+►rt###Ndk#f <br /> SECTION 3- To be filled out by eontrattor adetantaminating tank": <br /> Tank Decontamination Contmctdr: T gees o.s <br /> Address: p.0 <br /> Phone x: <br /> Authorized five of contractor cettliying through signature below that the tank hes been decontaminated in an approved <br /> manner as required by Cal EPA, <br /> Name: Title Signature; Date <br /> +•ft►##Y*iiiws#WWM*Ws###Wr1.W4###k#rrr#rrikrrrkkr++►rtfrWr+++t►##N#rrrr#kt#r#rkik+#w Ntkrr+*riiiw7#rrrkr*iw### <br /> SECTION 4 -To be signed and dated by an authorised rnpnaaearative of the mattttcalt,storage.or disposal faculty <br /> accepting lards aWor piping, <br /> Facility Nwm:-('A Ca A <br /> � M , <br /> lot <br /> Addme: �g�9 a/ Aj](8 <br /> r . C lot.Y� ,._ .�Ci4" rlL :L_?J0' �,�,1 <br /> Phone4p/N11� _. <br /> Date Tank Received <br /> Name: T1tie: Siguature: Date <br /> #rt#W+ii#Wk##ii►###ffir+krp##fNw►MMMff►+Nwlk+F*#iWfkkkkkriA#!#P#+F*N+IeWW++##wrtMr+►wifkw►##kkrttt#rp#IY#rt <br /> SH 21046 (Revised 9111196) Page 10 <br />