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FROM :JIM THORPE OIL FAX NO. :1 209 360 1851 13 2005 11:27AM P1 <br /> SAN JOA1QUU4 COUNTY PUBLIC HEALTH SERVICFS <br /> EpWIRONMEN'TAL HEALTH DIVISION <br /> MERGROUND STORAGE TANS DISPOSITION TRACKING RECORD <br /> wrYwrrWW.r�wWrwwwWY,YwwwWww¢rYWWAWWWWWW.rW,YM1WWMWWWWWwwwWr.WrWYWR.iWWwWWY#W..w..r.Ww�`�YYwWWWwF�wwwtYwwwwF <br /> XOd <br /> SECTION 1 - Public Health Services Envirottmenta]Health Division Task Tracking Shea sbaU seeompa>n'each tame Health <br /> Divi With <br /> its site ideatificarion number. The Tank TIacking Shea is to be rt w Pubes Heg hoklff is t�n"tn i��Meng� <br /> o,�*30d�of scocPn ce of the tank by the disposal or recycling <br /> this toren is completed and renamed. <br /> FACRjTY NAME: <br /> FACILITY ADDRESS: W G O D C <br /> PREVIOUS TANK CONTENTS: � � <br /> TANK ID+939-J De TAMC SIZE:� &1 ••-PR / <br /> ' WWptWwwWwwWWWFwWrwwwWWWWWWr'WwYMrtlwWWWw/wwwwttYwwrWwwwYwww.WYwwWWtYWW <br /> Wwwwwwwwsw�wwwr4*wrr <br /> SECTION 2-To be filled out by tank removal contractoLr:: <br /> Tank Removal Conu'A=:_ J <br /> v A : //✓, G/C / , City G e�2 I _zip: r9 Sa 1f0 <br /> te <br /> Phoac 2—_3L1-1"e Dare Tads Removed: <br /> ♦w.WWrrw.W+WWWWW+sWWstrs.wWWWW.WWraWSW.YwwswW+W*WWr+++w+'ts""rwwwwsrWwws.rwwww '+'ww�'Y"w"s'rrwn+w'wrtYw <br /> SECTION 3 -To be filled out by conu%etor"deeontandmating teak": <br /> Tank Tkrmmi„+,;on CoIICeCSOi;:7 <br /> Address:: 7 /1) .UG�/��/�La v City:_ GU00_Zip: C73 �9I <br /> Authorized representative of contactor certifying through signature below that theKbwnred in an wroved <br /> manner as required by Cal EPA. ts� <br /> Signattae: re [ /SECTION 4-To be sib and dared by an avthorimd reFwm"6 aofrhefresmany <br /> accepting tank and/or piping. <br /> EA) <br /> Fatality Nane:_ __�.� / <br /> Ctty' wD/ill� zip: A� r <br /> Phone : ) 4 <br /> Date Tank jReceived: OY <br /> Name: / �il C55 Title: Y s- Stere= DLJ D� <br /> WtW+•r4Yrrw.,FrWWWWWWWpW#w,FYW.tRrpwWWWwww,�Ww.4WwwwgW%WFt.WtW.wWwwwwWYwiWwq ,-- <br /> III 23 046 (Revised 10/19/98) page I tF=# <br /> ote 7671 Dale p# <br /> agn <br /> GO.phone;Fax# 36 <br />