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06/26/2003 THU 07 47 FAX 661 393 3834 MP ENVIRONMENI'AL-BAK IZ004/012 <br /> 05/30/2093 16:36 2054663433 FIFTH FLUM rHuc iv <br /> SAN JOAQEITI`l C0UNT'Y , <br /> irlvKRONMI;MAL REALTB DEPARTMENT <br /> UNDKRGROLTI D STORAGE TANK DISPOSMON TRAC)OIJG 2ECORD <br /> t#�r+#rrrwr.rwr�*�{*�.,�#.�..MMrR ss■tMr*w**w■**Wwww***MMew*aaN4F***USim ww** rwrrw,.■ #x*ss*ret*w=wrM rw <br /> SECTION 1—SIC gzvtre�tal Health Department's Tank Traeksmg Sheet shall acconVAUY eacb tank affi=d with iv ate <br /> idenh&sfion n=ber. The Tank Tmclang Sheet is to be returned to the Fxmromnsnul Health Department Yrithig3 p dam;of <br /> acceptance of dto tank by the disposal orracyciing faculty. The permit holder>m responsible for MUMS tlmt this form is completed <br /> and mNrued <br /> FA=Xry NAME. '7- Iff le V C W S40 i2 e- X2.3 7 14gi 7(v �- — <br /> FACUT Y AI)DRMS., 13'qct W. M A%N Nt^.J�ecy , CA ._. . <br /> TANY D7 639- TANKS=:.SIZE: 10 0Q 0 PREVIOUS TANK CONTENTS; fG9.&.0.{i r_q ._ <br /> ws#st#*s+swK*sM*wwyrynsw*errrr,ra#ntarows*r4s*w*sewwm'w IF*wow ww-w*wus.VwOmN«+ <br /> SEC`T'ION 2-To be filled out by tank removal contractor. <br /> Tafllczt= valco acior:_G�s�� c,� c •yui �Z�+y �w��l Se u�c� +c.. <br /> Addraas; �tle �?.�SSc�I �. 5�� �c City: r4lu�o WA 2'fp. -1 `" - <br /> Phone 3 aLk Y1atr Tauk Removed: /S'-O-3 <br /> #s*t#w##a*i wit# rF**ws*irt sir*N*w*rrwtiFwl <br /> Mims***#ss#sweet*iwsrwa sew■tr M#My"wHrY##+M#Rr■ <br /> SEC770N 3-To be filed oat by cootrnctor"doeontanuitating task" <br /> Tanis Decontaminaden Contractor. IAP +rucat t�OrU+nn�iV�� <br /> Address: 3_4DD MA ii -zce� --- ��Y���Ge�6�e�C� 7ip:_9�� - <br /> Firona <br /> Aathonzed upm=tative of sector cerd*mg through siguatum below that the teak leas been deconte1naced in an approved <br /> meaner as reTalred by Cal EPA. <br /> Nath w.0?1 -,_,,,„Title:A ARoa A-1-PR Smriature, sec <br /> ra:try.##*#***rtrt�k##r*wwMww•#■**a�.#ras***w r�xae■w■■■arstrt#trtrri:i#t.+F+*wwgry*tttswr■w�*r*##*ss*ssa"s■r+tw*wwW <br /> SECTION 4-To be sigae d and dated by an authorized representative of the treatment;storage,or disposal facility <br /> accepting tank and/or pVn. <br /> PNMW Name: <br /> AddrmCi,� 2 OGo l3RV�+rA�E GN �Zip[� JP" <br /> Phone#:( � <br /> Date Tenk Receivc& (01(03 <br /> Nww: Title- 1z".�h _Signature: ' Bate <br /> rrwse■urwxAtrs**s*+r4*Awrnaasa9*11I* M++s:irfwr+ewer*rti.ssf*sw.rYw**■**.re�Mirrsr+►sswww«*www*:*rt*wtw+*aw■wr <br /> r <br /> ZH 23 046 (Reined 3/I5/02) page 10 <br />