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ppppp"" <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANS DISPOSITION TRACKING RECORD <br /> www-ww www"ewwww,ewwr r e,"sw www wwwwwrwww**www wwwwr erswwr erwr�+�Mw*wrn�w�r+r*w�rrrw*rs�r+M+s�w,rwwwws�s.rs*sass r a*rnrww*ye rear r.r. <br /> SECTION 1 - Public Health Set-vi= Envixamm [.Health Division Tank Tracking Sheet shall accampany each tank afftd <br /> with its site idedfic=on number. The Tank Tracking Sherr is to be rennmd to Public Health Services Envimnmcmal Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> tri=g that this form is completed and tenured. <br /> FACILITY NAME: alz-c CLS 11'`,v'\ • Ca - - <br /> FS,CM= ADDRESS: �S S. <br /> TANK M #39 - TANK SIZE: rfREVIOUS TANK CONTENTS: � w <br /> v <br /> *:—er-w www=.��yewswwr ww wwereew www-rrzwz=swww+ee z zwrw w wzrw weever�rr+pwzsw=ww*rwwwr=zr rrww wwt.wzwzr�+e�e+n�+r:zz.�==is r�.w=r arw ww zz w= <br /> SECTION J -To be fined out by tank removal contractor- <br /> Tank Removal Contractor- k i K7,% r,\P A- ��,�•'ter-.••� .�a�� L�� ��os J�r_o� �v�C -- <br /> Address: `7 .vL, C1r� •a-:— City: �iS='•s:, Zin: <br /> ' t <br /> Phone #: ( QC0 Z -7!H5 Daze Tank Removed: <br /> .-rMw-z==w--ww-=r=--wz---=s---www*wr-s-ww=---rww=w-r=rete:ww-zw-wwwrw-rw=-r=-ww=w-=--------- <br /> SECTION 3 - To be ailed out by contractor "decoumminating tank": <br /> Deronzaminarion Contractor: :��':c:.,— �• \C\� Yin ^�•'� \ C S = �1�-, <br /> Tanis <br /> V <br /> �- C:ry: C.L Zip: E <br /> Address: � �-- I L'�� S-�'�.-�.�, •— <br /> 1 <br /> Phone #: =,_ r- <br /> Authorized representative of contr=or c=fifying thmugn signature below that the tank has been dcantaminatd in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date, <br /> --z==-z=w--w==-z=--wz=:------x----=x <br /> SECTION-t - To be signed and dated by an authorized representative of the me= storage. or disposal faciliry <br /> acting tank and/or piping. <br /> Facility �Fatne: <br /> address: -zz L4 <br /> Phone ,;`: (--22- ) <br /> Date Tank Re`."ivd: <br /> Name: Title Signature: Dam- <br /> ------------ -- <br /> atea------z=:r==--xxEH 23 046 (Revised 91111K Page 10 <br />