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05/30/2003 16: 36 2094683d`� FIFTH FLOOR PAGE 10 <br /> SAN JOAQULY COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> WwW#t#MWMwfs#MWw*s#iWWkxxYYWMwk#sasWWkW*is##wwMM=#ssY#MMwkzY#WiMWsxWWww#sYWMeW*s#MW Ww#*ssYWWMMzifWWW*xXWW*xYxM, <br /> SECTION 1-SIC Environmental Health Department's Tazk Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br /> and returned. <br /> FACILITY NAME: 7 - rE t'e u c vtl 5f0i2 e 2.Z3 7 Go <br /> FACILITY ADDRESS: t 3 9 ct VU . t-t A +,V M A wU�--C A C e4 <br /> TANK ID 439- TANK SIZE: 101 UCS O PREVIOUS TANK CONTENTS:_C A Sp(+rV C <br /> fMcWMew WOK*t#iWWM**s#+K#WWMR*si##WWWiMkMcksts#kwwl wok###xF ywWMM wsii#Nww**xycWWWIc*###WWMM**fs#*Wwwk k;ifK WtNwyc*aex#*wMk <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: G(Acir- z l�rVe�t2o+� Mew�,Al Se+2u+CC �•wC <br /> Address: Melfi, 1 .055r_tt Rb. 5w( kr A City: ty(uec>! WA Zip: Ct92Z5 <br /> Phone#: y( 2 5 ) 3 5S- Z s Z Lo Date Tank Removed: <br /> M*#sfsWwwMWiW*#WM'wwk*sxs#WWWWWMYYaxxyXW+NW.Wwhkk*xYYWWWWwkYleszycy*Ww:M*###KMWkRks#*WtNwwW*tasYKMtMwkwle#z#yrMeWwWle*s <br /> SECTION 3 -To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: M2 L vuU t 1Zt)vt)v�2.R1�,A 1 <br /> Address: 3 DO MAyUO+Z 54%ce� City: 8RketZJ)tk& Zip: G330$ <br /> Phone#: (,( � 34 3 - 1 l J l <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA_ <br /> Name: Title: Signature: Date <br /> 1k##i#i WWWwtisfWWwkkiWs#ic#KW WWW+hilYfxi*f#W WwWkw*f#fs#fi*#Wwle:likzlMcWWkM*sYY#WWWMWf#s#i RWWwkW*ffi#WWwkwWM*Y#s# <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping. <br /> FacilityName: C t20Sb�? °4 <br /> Address: l 6 t O We-S+ L-[-"% City:_t.,p G Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> *WwW##:#YMww*#xsssf�wwW:#x:sssWWWWMW*f#sx:s::##WWwww*kxfssss*rwW�asxi#iWWWk*sfs##WWWMwMMfissfs#MeWwwMsxfsss <br /> EH 23 046 (Revised 3/15/02) Page,10 <br />