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.12/30/02 PION 1 8: 3,'l I a\ � i 003 <br /> SA N JOAQUIN COUNTY PUBLIC Nt6AUHI SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE.TANK DISPOSITION TRACKING RECORD <br /> T*TTT7�RtM71 44.41*.TT14..414444•II.TW,P#T141++1f+IT4+44.**0r.sxTTTYYI'Wx••+♦TMT.Mrrt•rtT4*•Y•a �� 9► <br /> yark• MWiiiTT <br /> SECTION 1 - Public Health Services Environmcntal Health Division Tank Tracking Sheet shall accompany each tank affitted with <br /> its site identification number. The Tank Tracking Shve is to be relunxd 10 Public Ncalth .Servicc6 Envlroruncrital Health DjvltitOA <br /> within 30 days of acceptance of the ianl: by the disposal or rccycling facility The permit holder is Uegponsiblc for ensurlttg that <br /> this form is completed and returned. <br /> FACILITY NAME. ,Q�� <br /> FACILITY ADDRESS; A19 <br /> TANK 10 ►Y39' TANK SIZE: L PREVIOUS TANK CONTENTS,1��(f��/ <br /> J#M*i0R ii*a#ani►*st*#xa##W#**&l*taK*W**ii#WrtiMRFRRMi■MMrfir/iRiiR■rtrksR##iW►***#az###iiW#4W*MWr�FMikN*i!WWW»ii / <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Rcmovat Conntracior <br /> Address: II�JO L iQ�( <br /> ,/ City <br /> Phone y: �Y"a�.a+� Date Tani:Removed: <br /> #MRrt#Ali*rtrt4*isy*M**ss*Wz»Wi##►**iW#**s#*•»•#i.y.b####ilrtirWF*zz.s#s#4#ikq##rtArti•#4#tart•.ast..r+•ir*wwwrW■Ww# <br /> SECTION 3 ;To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Conlraetor. <br /> Address:_"Ve240' f�fl5014,4" c L[� City:LZl�� e�/9- Zip; CfL� <br /> Phone#:g} <br /> Authorized representative of contractor ceriifying through signature below that the tank has b decontaminated in an approved <br /> mariner as required by Cal EPA. <br /> I — <br /> amc: -Title: Signature:: /Date / <br /> *•r,F+ix••x44••x».t►:s*ary*{rtx•4x*#»'#c#r.r»xwx*xsrxw»**»WW*iW+kiM*L►K*t**i•#xk* »sxc:s»p*ai#�i}f#•#s <br /> SIrMON 4 To be signed -end dated by an authorized represtnWlvc of the treatment, storage, or disposal facility <br /> i accepting tsnL-and/or piping, <br /> Facility Name:L I�SJ�S - F'1/1 <br /> ' <br /> Address: City: zip: <br /> Date Tank Received-- _ --- <br /> Name: Title: <br /> Signature: Date <br /> Mi'RT?sTMW►Mt*r+wrM.•rs#Ws•s*wNr r�www�'n7 T'IT T.Y i�T*4.Tr.►fie.ssartrrt*RTwT}RwaRM+*r»irrrii4Ti###iiifl�}i{AFi+i . <br /> Ell 23(116 (p.,r_�issi OVI"I./44) I'agc 10 <br /> c <br />