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06/26/2003 THU 07 47 FAX 661 393 3834 MP ENVIRONMENTAL-BAK Z005/012 <br /> 05/30/2003 16-36 2094683433 FIFTH FLOOR rF+uL In <br /> SM JOAQiDW COUNW <br /> EN#IRO'VIYI'ENTAL REALTId DEPARTM NT <br /> UNDARGROUND STORAGE TANK DISPOSITION TRACkWr,ItECORD <br /> ' •#rrwl■rrri■r■MWW»ss#■*#ia=■saWlYMs.,kr##s#s*#Wwkfssf#s+kNMsrrslltss#aiWWasa#rkrWlOilMiksT+lcitt#171�krrr#k*14rWW*■�■ <br /> SEMON 1-S3C Fuvimnm=Ml Health Department's Tsz k Trecldng Sheet sW accompany each tank effi=d with its site <br /> ide=cation member The Tank Trackbu Sheet ism be retuned to the P=vlroameatal Health Davar=d=txMjn 30 days of <br /> the took by the disposal or recycling fatty The permit bolder is raspansible for onsudug tbat thig form Y coo:ploted <br /> and rutwme& <br /> FAtr1I.ITY NAME. 7_ E toy e W 540"Z e. 2.7.3 7 - 12417(o <br /> FACILI'T'Y AUDMSS: 13 R R W. &i A I rU M y%+N 6c A4 CA <br /> TANK M#39-_!a62TANK SIZE. 1P,000 PREVIOUS TANK CONTEM: Also{ ry <br /> lr�rgl■wrrwsk*sk#*!}yrkk!*#4M#R�+F#k Maf+Mav#+rtia(19 RRuzf�kW W*Mi■i■*yki sk'##sMukw W k■i7�e+Mikr7erK W wt*sR#r1tKpR7t�W#r.kMf*kk <br /> $EG'TION 2-To be filled out by tsmk remora{eoutrnctor. <br /> TMkR==velC=trnctort Glattc,z <br /> Address.+kLt l_laV,e l l 1 + �,,,�r A G�hr'„MtaSt,E�eo, W A Zip, <br /> Phone#: 4 as J 3 5 - z S?-Lo Date Task RLmoved; o <br /> *71�lsMl�IWYiriikiilF+k####�q r*ists�krwkiNMfuiklY#Icss*ssyf*#i.siMkMw*#�wiw![lnKM#■Frs'W W*iici#s*irasMW krr■rMk*w4�*i: <br /> SEC210N 3-To be filled out by contractor"deeontammatfag task <br /> Tank Decontmmiaanon Comtacmr. <br /> Addross: 3 A c City: 1 zip. <br /> Phare P.(&(P[l 343 1 S S, <br /> Authadzed representative of contactor ceraf*g Rough g pature below that the tatrk baa been decontainated in an approved <br /> :asnnr.r as required by Cal PPA <br /> NO= .,_ y Tide-M p J��,f _91gaa Dox � <br /> I <br /> lWrssiWsts*rra�nwR«skx**s�rw■Wrrrsrasss�rkstks*ssssss#s#wMaM+M+++rsgnF�r+MMt••+rt*M*rM+M+ist#�ks�kw*Mw■t*wsktw�*r <br /> Stt=Ov 4•To be signed and dated by am authorized representative of the ueatmamt;storage,or disposal facility <br /> aceepfiaz tank and/or piping 4a�>a ,t.J <br /> v.v city zip: R.r3g <br /> Plume ok r a/ ) 3 <br /> Data TLC&Fwceivtd• 3 <br /> Natue; Titin. �i'C Stg,einture• ate - �3 <br /> i <br /> i#rrir■rM1,r!lfcki+!!■pM■■■**&Down F*!Y#lkss**ss#i'tI *ki+rrslsYSM wR**s;wr sw*��MA•+r*#W+i#*#**R+FiwRwR71*f!s!#sss <br /> $H 73 046 (Rsvtsad 3/151QZ) Page,10 <br /> Y <br />