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FEB 28 2002 3:36PM <br />49 <br />ENVIR <br />.. ..... I. I. I............ <br />SECTION I — S1C Envisorur <br />.eennr:aone number. fire T; <br />..:c;unec of tpc unk by she <br />^I: Ire :nd <br />N. <br />7A'"!L!T'i ADDR.=SS'c- <br />' LRSERJET 3200 <br />k663433 <br />789464 1 38 <br />EHD • <br />ENVIRONMENICL HEALTH <br />p.2 <br />PAGE ". <br />PAG= iDl l: <br />NMENTAL H�ALTH DEPARTMENT <br />SAW JOAQUIN COUNTY <br />Telephone: (209) 468-3120 F= (209) 468.3433 <br />RCROUND STORAGE TANK ;DISPOSITION TRACKING RECORD <br />..........................i.•.........IN..p...1................................ <br />Inl Health Dcpaamcer's Tank IIncktng Shen sbaU accompany fach tank efCaed with iu ,Br <br />k Tracking Shaft it to be resum d fo the Environmental Mealth Department 1 Jtln 30 dayr of <br />ispmal or aeyelmg hcillry. 7}w Permit holder i+ r.sponsible Cor ensurlog <br />that dsis form Is <br />19 ah TAASIZE:�dOCNhn' i <br />.... i.ru..... n...f... n. arcrr..................... <br />SECTION : To be f1hed out b lank <br />)I removal contr.rtor: <br />Tr.k ftrWval Consanor:, . rJr 6LTM� t !]. f <br />Cow Tank Rem <br />i...u...•u•nU....r•.. •.... Lr..nu............ <br />SECTION 1 • Tc b: 011ed out by cOnlraclor "dsxonhmina GnR sl <br />.. Dc. en <br />s n R..nahan Conmm le•r..J S� <br />INS TANK CONTENTS: oy,VG <br />.a..r..nn <br />..................... v.............. <br />City�C C T 7ap�s2� <br />........•.................•......... •... r........... <br />.i•.:.a::rrd tcp; ncnnlive of c ontroctor cartifyigg Iheollgh signature glow <br />r rr.er a;feu}rd by Cal EPA. b ern deconumina ted In an approy:d <br />Tidr Nfe <br />Dalt12.— <br />....................... <br />Y— <br />.......r.........•.....•un •n uur. r.. r.......uo.a .Y.n.nwu H.... <br />,cce o+be signed and dat d by nn aulhorimc! rapreseola Iva ofthe IMMat, sturage,or dispostd (AMily'("•„'••'• <br />SZCTIONa• <br />Fli:y aN"rtfir�;E�.OrBf' ( <br />C.i I. zip: <br />kit <br />....................... ....... .......... <br />•q....•.. u... 6 .............. <br />=H:• :+3 IR:.,ecd 11,21/06) 10 <br />