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�..� <br /> ;NEW <br /> SAN JOAQU3N COUNTY PUBLIC EMALTH SERVICES <br /> ENVIRONMENTAL EMALTH DIVISION <br /> UNDERGROUND STORAGE TANK DIISPOSPTION TRACMNG RECORD <br /> �swaia*.Ywa.+k.rlr.�s.�rea.rr//r..w.. rr�swfrris�M�t..ye*s.�Rr/r....��r*ra.�safl.*.r.aw.swsasrasas=errae�ra.r s <br /> SECTION 1 - Public Healrh Scry=EnvirO=c=al Health Division Tank Tracking Sheer Shan a=mgany each tank affixed <br /> with its site identification number. The Tank Tracking Sheer is to be r=nd to Public Health Services E,nviror cnml Hcaith <br /> Division within 30 days of acccpm= of rhe rank by the disposal or recycling fdUry. The permit holder is ressponsbie for <br /> casurmg that this form is completed and rcmmd. <br /> FAC ZrY NAME: [`C'� L� 0s mc, <br /> FACILII•Y ADDRESS: S S. SCC` <br /> TANK M #39 - TANK SIZE: Ct, PREVIOUS TAJ K CONTLNTS. � 1 <br /> rrrrrrrrrirrarwas.wrarwaasrrrr+ussw�rsaa+Msrr+rw w.rs:•rwawrwr+n�wwaaw:aFrrrrsawswswrrw::rr:rwrrsarrrrraawarsrr <br /> SECTION '_ -To be filled our by tank removal contramor. <br /> Tank Removal Contr=or. �, r-v, ;-rf <br /> v <br /> Address: l^`7 DC.1 cd •�.'; cry: ',�=-.—, Zip: c� r 1 r — <br /> Pone #: ( CZC0 )�g Z 0-7 CC _ Dare Tanis R=oved- <br /> -----mm... ---- <br /> emovedrrrrrrrraWarrzarrrrwrrrrrrrarrrrwwr:rrraasararwzsasarwfrwwrr: ----------- <br /> SECTION 3 - To be fiild our by ca or "decontaminating =nk": <br /> T-nK DeC. n=n m:S cn Con==r <br /> 4 <br /> r <br /> Phone <br /> Authorized :•enresen=ve of con==r riiying d1roug signature below than the :anis bas been de~antamina=m an approved <br /> mannrr as .m-j by Cai EPA. <br /> came: L ltle: $1gII3n1ie: Dare <br /> :,rrrrrrwrrrrrrrfsrrrrrr:rrrrwrarrrs::rrrrrrrrrrrrrarrrarrraaawr:arrrrrrrrrrrrarraesrrrrarrrerwrrsarr.......... <br /> SECTION .4 - To be signed and dated by an authorized representative of the trcmrar. e• or disvasai ar:iirl <br /> ate.-piing mnk and/or pining. <br /> Facuty Name: 1 A":L---: <br /> Address: <br /> Z!D: C'• G <br /> Phone #: <br /> Date Taak Rived: <br /> Name• <br /> Tule: Signature: Dam <br /> za:wearrrrrrarrrrrrarrraarrrrraraarrrrawrrrrrarr:'rraarrrrrwrr:rrrrrarwrrrarrrrrararrrrrrrrrrrrrarrrrrrywr <br /> ME 23 046 (P-viscd 9/11/96) Page 10 <br />