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0 <br />ENVIRONMENTAL DEAL' <br />SAN JOAQUIN C <br />Telephone: (209) 468-3420 Fm <br />UNDERCROUNDSTORACE'TANKDISPOSI' <br />..«,...«..«..,................. ........... ....c.............. <br />SECTION I - SIC Environmental Heolih Dauwnem'E Tank Trucking S <br />identification mon'ocr. The Tank Tracking 51seet Is to be re4+mcd to the <br />noccptan:o of the tank by d.c disposal or mcydjng f.cllkv. 'MI permit <br />cnmploted and returned. <br />FACILI'TYNAME:, I n <br />FACILITY ADDRESS:_q`-- o <br />TANK IDN39-_QL,_TAHKSIZE: 1�- PREVIM <br />.«.,,....«..,yet..........,,«.,..r.n.,..er................... <br />SECTION I - To be filled out by tank rreemavnl Con <br />Tm,k Rem oval ConaooW r__. I t%i \l.i� ✓ �� 7 IT U� <br />Phone is LO 31 , 14 Dale Tank Removed:, <br />•...ya...,....w,......r.y«y...........................«. <br />SECTION 3 -To be lilod out by contractor <br />�"dtconnmioating tank": <br />Tank Decontamination Contractor, OC- GsJ <br />DEP <br />Ll <br />9) 468-3433 <br />TRACHINC RECORD <br />tall accompany ench tank oYnxed wlth;'iis site <br />m <br />oental Health Depattmcut witaln 30:diJs of <br />r to rcaponalblo for ensuring dint titin,f?tiu h <br />yam u_ Cl, q s -M (� <br />Ll IS - <br />Autharlud mprw-mtntivo ofoontrnctor cestifYin& <br />x( <br />through aignamm below thot the took bas be deconttminated in 8n approved <br />manner m tnquirod by Cal EPA. <br />Namc: wAi T uRsaT!ts.bRN Titiv. <br />UatetZ�(�[J <br />.Tyr*.yTykt.r}rMa.iy.tr.ytkiy,r}r..ra!krr.,}a..4ray..rr.wyr.M <br />T4}e,yfR a*}rMYtlwrn..}rfr,tyK,.y}rAyrry.} <br />SECTION d -To bit signed and dated by an attthedzed rvpmsetswive o Ent, stutago, or disposal facility <br />accepting max anwoorr piping. <br />IN tj <br />rFodlity <br />�� <br />Dlamm <br />i <br />Addrms: SOV��� <br />( <br />j'11(`� _("Va----orm ce- Zip <br />�fIV(LO/QICy%..I,�Q,,. <br />q <br />Dnro T , k Rcc<ivad._ <br />+', Tq.s h/+�eCr53 i.t �%Ulx7P�,',/ <br />Noma 3, N S,u C i Tnio. $sbnaMMto ![ as <br />m �t - <br />.[)nsc <br />...........................: <br />„1 } <br />EI•123046 (Rcv)sed 1IR1;06) <br />yr <br />