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10/17/2000 04:00 2094683433 FIFTH FLOOR PAGE 19 <br /> Y <br /> SAN JOAQ VIN COUNTY PUBLIC MiZALTH SERVICES <br /> Et+MONWMMAL HPALTH DMSMN <br /> LNDERGR4[JN1>STORAGE TANK DISPOSITION TRACK]NG RECORD <br /> s#fl "#1 t#herr*******0L****NOLOO*#fit*00***,&********** <br /> SECTION I.-Public.Hca3th Services Emmwnizu al health Division Tank Trs Idug Sheet&ball accompanyeach tank affixed w,h <br /> its site ident>fcation member The Tank TracklAg Sheet is ro be scturned to Public Health Sejvxces Env3t+onrnearal Heap b Dtvism <br /> within 30 AM of etaeptaaoa of the tank by the dispoW or recycling facility The permit holder is responsible forr=sunng that <br /> this form is completed wd rued. <br /> FACIL.ITYNA?.M_,_PACIICAVENUE ARCO <br /> PAMMYADDRESS- 6425 PACIFIC AVENUE ` <br /> TANK m 139- TANK SME- 10. 0 0 0 pRE jous TAM CONTENTS- GASOLINE <br /> SECTION 2-To be filled out by tank rmwvsi eontrmor- <br /> Tank Rcawvtd Corktrtctor: W, I N <br /> ,kddress. 5940 TREMONT ROAD City: RIS?-. Z�pl_ 9562n-96011 <br /> Pbone p. U 0 7 ) D$Ae Tank Removed: <br /> 3ECT14N 3-Tobe Med out by oomtrador "deconLnminatWZ tank". QQIES iv p A Q L <br /> Tank Decontamination Conrrsctoc: <br /> : . City: ZIP•— _ <br /> Phone 1:i <br /> Austwited represaatauve of contractor cenifytnS th=gh slime below tbat ttu tank bas been decas:tanilw d in an approved <br /> ma as required by Cal EPA. <br /> 'vame:.1ELAND ,Ir,ALELIS —Title: GEN . MANAGER S teOCTOBER 1 200, <br /> ■tiii�Fi#Ili#iak##i!***###!****#*#1iii**i+►!*t#*#t�lriil>Ri#**i****w*#*#!*i#i«+l*a*t#*ilii*#skill#!i#*#*!##t*ail�l <br /> SECTION 4-To be wgwd and dated by an autborhed representative of she trcaunent. enrage,or disposal facility <br /> accx 1qg tank mdlor piping. <br /> Fsciiity Nam: <br /> Address: City. Zip: <br /> ?hone 0 <br /> Date Tank Received <br /> Name: Title- Signature: Date <br /> t****t***i******0*Y«t**tl Mi*iit�f*w*Frw*a#ai#li*ii#s+►7Ts�*M#i*f**4+M�•�*fiiiytA«wttM7F iwv*yw+i#moi*tYM#****+rti*» <br /> EH 23 045 Otevised 08113159) Page 10 <br /> i <br />