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0 <br />ENVIRONMENTAL HEAL? <br />SAN JOAQUIN CC' <br />Telephone: (209)468-3420 Fax; <br />UNDERGROUND STORAGGITANK DISPOS111 <br />sw...nh.lxlOn.a..v.nn.....n........1................................ <br />SECPION t - SIC Envhonmentxl Heahh DoparrmenPs. Tank Tracking Sgt <br />identification number. Tho Tank Tracking Ueet is to be resumed to the E, <br />occeptarmc of thu lank by the dlspvsal of 1ecyvlN9 futility. The ponnit Il <br />completed and rammed. - <br />� t _ <br />FACILITY ADDRESS:__`T0 L=-__ I`kw^ <br />TANK ED N39 • TANK SIZE: I L <br />.................................................. <br />SECTION 2 • Tobe filled out by tsnk removal contractor, <br />Tank RarnovN Canrractor. 7� �Atv"N <br />Phone 4:(_03) > - �� Date Tank Rrntovcd: <br />•.nn.nrV e...q»........................00I..ddn..uu...... <br />SECTION 3 . To be filled out by contractor "deeontnminating rank": <br />Took Deaonaamination Contractor. <br />41 <br />I DEPARTM +'NT::' <br />JNTX <br />09)668-3433 <br />a TRACKING RECORD <br />•........... 1 sten. w_w. _w....._ •MM_ we <br />shall accompany each tank afOzed wldr4hs she. <br />'onmenuf Health Depumnvm'stet fila 3LiU Of <br />ser Is responslble for cmurmf That dals-Sbon <br />o ,nom c ,CAS 9 3 <br />�z q) <br />Phone R: (.r� 17 <br />Aulharized teprwentalive of aontmetor certifying tbrovnh eignansm below that the tack has Inc derojimminated in on approved <br />manner as raquired by Cal EPA. <br />Name: wt T. anfsrn2eV Title:,s'�i'± Sigrvt Date,._ <br />•.i4e1..Inns:kkMeikk.�.RR.�rW..FT}alf.eT�pk*.TM.YTttaas..Mae...eM �Yy:fTTTe ...TQM.1.kA..4T6..ilifj.Vf—T.r..a�a>.f. <br />SECTION d . To be signed end dated by an authorized reprnrentative o ear, stvram or disposal facility <br />accepting tank an-dloor-piping. e;•' <br />i6> � <br />Facility Nartw; rl'' <br />Qint"."R,!51 <br />Phone 9:(3� ),, ,, - S �Y� _ <br />Dat. Tank Rcccivice��16-L64— <br />Namc; . m6ls %ll ICC)% Titielyy� fYtr lgnolur�c <br />.... r ....................... n..rl.».r..a.o..ui.+. r...... uau <br />EM 23 046 (Rewscd l l4l/06) <br />.e........ ................ <br />