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FROM :JIM THORPE OIL FAX NO. :1 209 368 1851 r. 13 2005 11:27AM P2 <br /> SAN 30AQUINN COUNTY rUBL,IC HEALTH SERVICES <br /> ENVIRONIALIVTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DLSPOSTTION TRACSING RECORD <br /> ww.w►r�r.asrws:ss�••�••••••••rarrwawwra+►*ww+ynww►i►rs►+ws+.r+�r.wwws+swrrww.�sr+•ra ar.r <br /> SECTION I - public Health Sm-vi= Em iroamtosal Health DrAsion Tank Tracking Sheet shall acc=Pany each tank afted with <br /> irs size idenaficanon number. The Task Trac1=9 Sheet is to be returned r4 Public Health Services Environmental He"Dwwan <br /> _ of artepM=e of the tank b,the disposal or recycling %, cl ry The permit holder is rasporzstbI for ensuing chat <br /> thin form is colleted and rez®cd. <br /> FACII.ITY NAME: 3 ` <br /> FACILITY ADDRESS' c2, Wig 11,'�Z e D LZ 5/!' <br /> TANK ID/39 - d/'i300.5 TANK SIZE. PREVIOUS TA.AIK CONTENTS: <br /> SECTION 2-To be filled otu by tank removal connact0r. <br /> Tank Removal Cont tor. J o f,' 4G- <br /> Address: 3 Sf �7 /✓. 3 Z G/Ciz"fej Cay:_ 1G- Zip-_9 Jaz �Q <br /> Phone f. (tea,�) T �� 3 / e9 Date Tank Removed 2/ <br /> S$CTTON 3-To be fled out by contractor"decontamb2aat-iing tank": <br /> T=k Decomami 3arion Contractor. <br /> Address: S� /� 13� �/�lfla City: 16�( zip: ��-Z fg <br /> Awlarh=4 representarm of caatractor cer fying through signature below that the tank beat decomamivamd in an aFroved <br /> mite'as mittired by Cal EPA- <br /> S_ <br /> r�I � : D a �` _7 <br /> SECTION 4-To be signed and dated by as authorized representative of . s�+$e.ar dLgxksal facility <br /> a=cpting tank axtWar piping. <br /> F2iliry Name: <br /> Addr=: � S/ city: —, Zip: � <br /> Dano Tank Received: <br /> Name: r��,� T _ s Sige �0:3=,14" <br /> D� <br /> wrwowp�.+gra.varwwr�ww.rarw�arwwr.�.�s+.r�.maewrw+rwww+aw+rw�wna�ermwww+awr+ww w <br /> EH 23 046 (Revised 10119/98) Pap 10 <br />