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10/17/2000 09:00 209461 33 FIFTH FLOOR PAGE 10 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANICDISPOSMON TRA C IU N G RE C ORD <br /> WttWW!•FkkiRWktii}W}#}W#+*}*}*fitrWR*R.RRR*RR*}WrriR}Ri}*RRr*trtWiiWMR}RWFRNW1rtWMF#RW#RRRWRWR##�Rw+FRRl;tkRRRW <br /> SECTION 1-Public Kealth Services Environmental health Division Tank Tracicing Sheet sball accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet Is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit bolder is responsible for ensuring that <br /> this form is completed and renuaed. <br /> FACILITYNAME: PACIIC AVENUE ARCO <br /> FACRITYADDRESS: 6425 PACIFIC AVENUE <br /> TANK M f39- TANK SIZE: 10, 0 0 0 PREVIOUS TANK CONTENTS: GASOLINE <br /> krtttMi#MFt#M;;ti;Ft};MMMWrtWMWF#t!#Mtiitttri;Ri;RwiYW;;#WrtwiFRWiltlrilrRRRr#rtwrtF;MWWM#wtw/FWFMM;Y;YFMRMMFMMF <br /> SECTION 2 -To be filled out by tank removal contractor <br /> Tank Removal Contractor: W. A. CRAIG, INC . <br /> Address: 6940 TREMONT ROAD city: DTXQN Zip: 95620-96U <br /> Phoned: ( 7 0 7 ) 693-2929 Dace Tank Renwved <br /> !MlffrtfiiW#it;YtM#•rt►YFF##iiiirirrrtiiiitYMWY#MY#MF!lrtrWiliYWw►FW+I##Wlririr#WFRMtWMMFWwiwkMMi}iiririirwir <br /> SECTION 3-To be filled out by contractor "decontaminatin tank": Q OiES tai O% A Y Q ly <br /> Tank Decontamination Contractor: <br /> Address: City:_ 2.1p:_ _ <br /> Phone#: <br /> Authotiod representative of contractor certifying through sipatice below that the tank has been decontaminated in an approved <br /> mariner as required by Cal EPA. <br /> Name: LELAND YIALELIS Title: GEN. MAN GFR Signztd �teOCTOBER 18_ 200, <br /> WRWIwrtWWRMrt;R;#firtitriiirii4fitYrrYit4F#rRl+ftri*YwWwwMM;RWFlrrtYFtWFtYWrrtktrirf YYWF;WYwrtt;tMi FFriitrrrRri+F <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: <br /> Address: City: Zip: <br /> Phone f: L_) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> !iW•iffffltrfirWitWYYlMYwRWYFrtiifrirrwrfirF!!#YYirrwiTfirYY'friW4YrvrrirriMWriWWMrirMrrrrlrr*riRiWMWrWii• <br /> Ell 23 046 (Revised 08113/99) Page 10 <br />