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01/07."200' Lie:23 1 F1Z'ADAIW-, SFP%..-'TCE.c., JF!,- <br /> 1.9/30/02 MON 18;36 FAX <br /> 1004 <br /> '-:Arl MAQMN (A)UNTY I'l III IM <br /> 1�'NVIR()NMI,,'N*I'AL 11FAL'I'll <br /> JINDERGIMUND S'101(A(;)-"'['ANK DISPOSITION TRACKING Rvcolm <br /> 4 4*4 4+#--'. t� 4 4'R.......I.I.4.. 4.V 4 6*+..**#++4 4 i.-**4*44•4-14-4r& + }+44444 <br /> SECTION I Public Wralili Scjvice'; I'llivironflIC)INI Ileallh Divisioll,rfLni, Tracking Slicc( 51I.All aCCojTjPRny each lank HfrjKr.d WiUj <br /> its rile idel)(Ifick(ioll 1111robvi The 'I alik. Shco is (o hc returned to ptiWic Health Services Environn-icrital 1-1calth Division <br /> wIthlit 3b dui of-wCcpwncc of the (anL- by the (firl-yjil (), Tc:cycling facility T-lic perml( holder is responsible ror C11surkil; that <br /> (fils form Is complett:4 wid returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANY,JD#39-,01jLALiq7 TANK SIZE: L ppEVIOUS TANK CONTENTS' <br /> **44*0 *0 0 t*0 4 t*44*t t*q, #of <br /> SECTION 2 ,To be rifled out by tank removal contractor, <br /> - <br /> Tank Removal Contractor'—&---Z-� red <br /> City <br /> Address: zip.- <br /> Phonc ff: Date Tank Removed; <br /> **4 4 444 A** <br /> SECTION 3-To be filled out by contractor"decontaminating L2AV; <br /> T,,wnic Decontamination Contractor-. <br /> Address- <br /> city <br /> Phone �O <br /> 'i Authorized representative of conct-Bctor cci-lifying through signature below that the mnk has be ntd an approved <br /> Manner as required by Cal EPA <br /> Name: 9YbC-t9'- Am-5 Ti0c; o r— <br /> *4*4 44 <br /> SECT70N, 4 To be signed and dated by an authorized representative of the ti-catracm, storagc. or disposal facility <br /> accepting tank and/or piping. <br /> Facility Nivne: <br /> Zip. <br /> Addre.r <br /> rbooe r: <br /> Date Tank Received:-�&"- <br /> Title: Date <br /> n <br /> p:!r.o 10 <br />