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4-06-1998 8-59AM FFItAIT SACRAMENTO 916 6.'7E 2606 . P. lo <br /> SAN.IOAQUIN COUNTY FtMLIC HEALTE SERVICES <br /> ENMO NMENTAL HEALTH TgACKLNG RECORD <br /> UNDERGROUND STORAGE 'TANK DMOSITI <br /> �r� ry„i„rrt..rrwrwrr.rrrr*r.a++rrrr+ww►r <br /> affixed <br /> rwrr.rrrr..rw►s"'.'°+'*'r►'orrrrarr+r+w.r ,.�y ..�VMAMmcntd b DiviBiM Tank Timg L St19IlmPmY �h � <br /> SE('"I'IOit 1 - nific i Health Sa.The Tank Tlarking Shea is to be rcm=cd to Public Health SOT=rnvito==W Hefter <br /> rad <br /> with its list idcn30 dmLVI m�xr• of the tack by the l O1�Yd3 far.Iiry. The permit holder is responsible for <br /> Division wit�.2�+��of��� <br /> ensuing that this form u wrapicted and rcnuncd- <br /> FACILITY NAME: N&,,A L, 5. _ <br /> FACILITY ADDRESS: <br /> TANK ID x`34 '_ .,.- TANKSIZE: ! <br /> 2 p,�c f- PREVIOUS TANK CONTENTS: q t'_o Igo df <br /> rrwrtrt...rtraart..rrrrar.r++err+.rrrw+rrrra.w.ar+w+rwcrrtrr..rtrr*"'rrra.wrrrrw..rrrr..�rrtrrsrwrtr+�rrr+""'.rwr.r.r <br /> SECTION 2-To be filled one by tank removal cowactor. <br /> Tank Removal Contractor. <br /> Address: <br /> Phone C ( ) Date Tank Removed: <br /> rrrrrrrrwYrrrM�rtrrrM.rMvaA..rwrr.Mr.rrx+FM1rtaYXrrraMa <br /> .rrrtrww+rrrw.ar..rrrrrrrrrrtrrrrwrwrwrrrtarrrw+v <br /> SECTION 3 -To be filled out by contractor "derootaXELnOOR9 Cmkr: <br /> Tank Deaonratnumtion Cam <br /> Ciry: -Zip' <br /> Address' <br /> Phone I' (Jm an approved <br /> Attehori=d mprtScnt=vt of comraetor cerirfYiU&almugh signature below that the task has bila deconta niaatad <br /> ma=rt as required by Cal EPA <br /> Natne• Tule- <br /> Sim Due�— <br /> • rta,yyrprrtrrrYMWMrr��rarrrrr#rrrr.r+1�MTVartrwrtsaf.r+krr4O'Frrtrarr <br /> carrON 4,To be signed mid d by entzdve of the treatmeet,storage,or disposal facial <br /> SECTION 4-To be signed and dated by an aathataed rem <br /> peplum tank=W40T piping. <br /> Facility Name <br /> Address: <br /> Phone f: ( ^� <br /> Date Tank Receive&: <br /> Name: <br /> TiUr Signature: DLJ--` <br /> rrrrrrrrrrwrrrtrr rinkwrrrral+/rrrrri�"�r <br /> .brrrtr.rrrr*a*r..r"`rn".rr«wa+rrrtrnrar«w.+r+rrrrrt.rrrrrrrrrrrrtrra <br /> EH 23 046 (RCYna:d 9111196) <br /> Page 10 <br />