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F � <br /> i� <br /> SAN 30AQtiTIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DrVmoN <br /> r UNDERGROUND STORAGE TANS DLSp0=0N TRACEING RECORD <br /> i� <br /> �larsrrararsa�rr:ar=�r�rarnrs=rwr+k+raerrr <br />+ iiwwaor�srasrsaarrrsw+gas=ara.r�rr*�aarr�=�+M+Marar =�� i <br /> SECTION 1 - Public Health Services Environsal Health Division Tank Tra". Sheet shall accarapamy each task affixed. <br /> with its site idcn t ion number. The Task Tracking Sheet is to be returned to Public Health Servi= Environm=W Health <br /> Division within 30 days of ac�ptaa of the tank by the disposal or recgcirn$fac'tty• T P balder is responsible for <br /> F eastaing that this form is completed and returned- li <br />! FACILITY NAME: <br /> FAC"Z= ADDRESS:_ <br /> .r <br /> i <br /> TANK ID n9 - TANK SIZE: R. TIOL15 TANK CONTENTS: G <br /> a V <br /> jF <br /> rrrrwrrrrrrworrr rrwwrra rrarrrrrrrrrrrawraarrr�Frrrrsrsrr'�=wrr'�rr'°w+Kr'°rr'�r*r�srrwrrrrarrrwrrrrwrreraaY rw,wsra++kwr r= <br /> sl <br />+ SECTION 3 -To be fMcd out by tank removal contractor. <br /> i <br /> Tack Removal CoIIMctor <br /> Address: {. <br /> F <br /> Phone : ( �c,C ) -7 Date Tank Removed: <br /> ■rarwr:rr:sarrw,wrrwwfrrwrrrrw,exrwa�rrxrrraw�xrrrrrrwarrrrrw:xrwrrw 'wri�wrrwrrrsw:xr=rssr::tiera�arrxa::trrrrrwaitrr:rxr� <br /> SECTION 3 - To be fined out by contrjor "dewnraminariag rank"- <br /> Tank De-,.ontamination <br /> address: r7 Sa,e,;, ;� C`tv: Zp / <br /> Phone P. <br /> signature e6ow *ball the rank bas been de�ntaminated in an mproved <br /> Author:�i:rare=etttative of===r�ryiag trough g3a�e <br /> mann: as mauired by Cal BPA. <br /> I� Date <br /> N amr- 7aie: Signature: <br /> ik <br /> :ww rwrrr------rxxrrrrrraww rrwrwrrrrr++r=rrwrrw rrwwfrfirwrr:yea�r rrrrr rafwrw,rrrrr::rerrwrrwrrrwr rr ss rrrrrr rra rrs r r as <br /> i SECTION d - To be signed and dated by an authorized reprewararive of die amu. storage. or disposal 1aC Hty <br /> ' acting tank and/or pipiag. <br /> t <br /> �k <br /> t F7=-:iity Varve: 'a �- �^c A- <br /> rl ,,�n i n' C- C--�,G �k _ZIP: <br /> Address: +'yr�l Li � <br /> clone 17: L.' G.1 1 �- l r•..r:� CU 1 r..a�, ./\1 1 - <br /> e <br /> Dau Tank Rc ived: E <br /> Name: Titie: SiQrlacure: Date <br /> 0 <br /> rrcarrrrr..�wwrrwrrwrr�rrwrrrrrrrrwr=wrrrrrrr�rrrrrrwrrwww,erwrrrrrrrrrrarrwrrrrrrrrrwwrrrrrrrswrwwrwrrrxrx:w <br /> :e <br /> ME 046 (R,—rised 9/11/96) Page 10 ,a <br /> - I ' <br />