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06/26/2003 THU 07 48 FAX 661 393 3834 MP ENVIRONMENTAL-BAK (a007/012 <br /> 85/30/2908 16 36 2094683433 FIFTH FLOOR r+4ur- iu <br /> SAN 30AQUIN COUNTY . <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSMON TRACYING RECORD <br /> A##,►w#r*M+Yriagew###r*rrKsacs#M#Rsss3'iI1RRrrrr*yrswiF#ssssr+k+hMw lis*##Aik.rtw*s#+kss+rwiRlr*kr#!R*#s7n/tRM�I.rsi#ilsoRrlW IFirace# <br /> SSCtlON I.-SIC l avtremu mtal Health Depan=es Teak Tracking Sleet shall acco=pany oath tank atIbced w4 its srte <br /> idennficatioa msiber The Tank Tracktn$Sheet is to be retamed to tho Pnvironme m1 Realth Depar=mtMain 30 dava of <br /> acoepunce of the tank by the duposal or recychag facility The permit bolder is tespoustble for enuring that duo form is completed <br /> and retumed- <br /> FACMTY NAME;_ _" - iEbe u C W S40Iii a ZV6 7 - I OA710 <br /> FACILITY ADDMS: i 3 Mt rO• MAIN M AvV GA4 CA <br /> TANK ID 03-0-50(e!52- 1 TANK SM t©,Uo O PREVIOUS TANXCONIEN'TS: A ref <br /> .<s#wr#1ts*Rfiwr+••rarWMws#x*s«#hkirer.ss*s.p stae�rRF A#M#w�*�'#1cMi[**##+R#rr�rycks#�nk*#*sickKAl. lr' K!wok##aw*iFf <br /> SECTION 7-To bo filled out by tank removal e6utractor. <br /> Tank Removal Contmcior. 11A C U t Ra ed-na&VAA 5 e a u 'Cw G. <br /> Address.414 ftp Roan(( �_�_,_ 550, tE i4 - City:Mukd Hca,.,wA zip: q8Z j .W <br /> Phone A( 4 Z Y_ S-- Z-6 7-4 Date Tank Removed:� D.r <br /> *#ss#�*#alis#s4*iA#*ss*+�###a#mess#rllar.#*+essss#**t#wkR#s#*s4Nw##*s! *w*Xe*i.ssiiMrN#s#*#.f1�r+h.rtss*#�r*M.k*Fra <br /> SECTION 3-To be filled out by contr¢etor"decontaminating lank": <br /> Tank Deaontminadon Comactor. Mtn F-wti t %Z0VV -,A 4" 3 4^ <br /> Address 3 ACmC v, dA2. S�2re�r „G��:t 1C� G. zip r4 <br /> Phone#,(We I ) <br /> Authorized tepreaentatnae of conbmctor certffyvgg tbmugh saws below that the task bas been deeantarmated m an approved <br /> mom=as requlwd by Cal EPA. f <br /> Naute: Glee~q 0d'sl,U,D0W\ _ Title. d +. 9igaatatreDate / v <br /> v!!!��#�■rr:r##w#*�#slr.+�wewwMarr:s:*s�»�xw�s�**sssss�srs#*��**,a�* ae**rws..ssasaa�e*!.r#rswsrsr��r+ <br /> SEC 7ON R-To be signed and dated by as authorized representative of the unat=n;=asp,or disposal facility <br /> aeaeptmg tank and/or piping. <br /> Fadliiy Name: aG <br /> 2000 8 R v Iu A A��' L Al r CR 3.3$7 <br /> Address: Citr Zip: <br /> PhMa#:(Gri_ — <br /> DaOa TAa k Raoclvad, l� <br /> Name. i0 Title: r Stgaafiace• late �a <br /> •A#•ssss,�ssM**atir r#W r ew r7ss7:�lfiM#+F##i+k+Rsss!lwwYMf##k#s#!#�,Irl#aMk#spMw�IMliros#fRa�r'l4lrhr,er*x#rye#Mwlrrs*#s <br /> r •E1123046 (Revised 3/IS/DI) Page 10 <br />