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Mar . 19 2003 0 07 PM No . 5666` P , 9/20 <br /> SAN JOA,QC IN COUN,.IfY PUBLIC HEALTH SERVICES <br /> ENI V IROINTNI:Ei*NAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACIGNG RECORD <br /> SECTION I - Public Health Services Environmental Health Division Tanis Tracking Sheet shall accompany each'Unk affixed with, <br /> its site identification number, The Tasty Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> withlar 30 d�of acceptance of she tam by the disposal or recycling facility- The permit bolder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: <br /> __PA-NN' <br /> FACILITY ADDRESS:^BD 5'C? <br /> �- TANK SIZE: PREVIOUS TANK CONTENTS:_ <br /> SECTION 2 -To be filled out by taA removal contractor: <br /> Tank Removal Contractor: +�--�'� <br /> Addrtss: City' &.1� Zip. <br /> Phone#: (-405-) -Date Tank Removcd: <br /> SECTION 3-To be filled out by Contractor "decontaminating tank": <br /> Tank Decontamination Contractor: � <br /> Address: p City:�� <br /> Phone#: (2J5 cl ) !jkj S -q°j -- <br /> Authorized representative of contractor certifying through signature belotiv that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA, <br /> Name: TitSe: 1 � ' _Signatur <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping- <br /> Facility Name: V <br /> Addressj r. 4n V 1 t C�i Y] ., CiEy_ Zip: —Z <br /> Phone : <br /> Date Tank Re�mtd: <br /> J4. v!R�4 5ry� iR.aWr <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />