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FROM :JIM THORPE 01L FAX NO. :1 209 368 1851 13 2005 11:27AM P1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVMON DgTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSYTMON TRACKING RECORD <br /> ��y;�rp,eYycsrrrwiaYOrs#4r*+rsrr r#Msr+Y�rrys+.�r.w#+SWM+��r'rfwssIWtMsr '�'rra,aarrssrs«ti�MMrtr,F,M4� <br /> SECTION 1 _ Public Health Services Environmental Health Division Tank Tracking Sheet sbaU accompany eacb tank affixed with <br /> th Division <br /> iu site identification umber. The Tank Trackiztg Sheet is to be returned to �HP�Shokler is responsiervices ble for ua �eas1ang� <br /> t�k 30J�r of ar�epta= of the tank by the disposal or recycling faciliry- <br /> Ihis form is completed and rem=d. <br /> FACIIm NAME: <br /> FACn_M ADDRESS: <br /> PREVIOUS TAMC CONTENTS: <br /> f TANK TANK SIZE: <br /> ID#39 - �f�� <br /> r.rr.r........w«+..+w......�.r...n.r...t...,ar...M.+«*.+h..,«.,r.e.rw*»,r�.....wr.....t.s,.,r.ww.erss...w <br /> SEcnoN 2-To be filled out by tank rezinooal contractor: <br /> Tank Removal Contractor: <br /> Address: (j �. city: G 042 -zip: f;2 <br /> Phone#: ( O_T>� •� 3 / O Dare Tank Removed: v2 <br /> rq�,rrr�Ars,asrrrw,►srs.�.�+�►err.ss s1FMrrtlFr*rYHM�11►1F,MY�rrMK+MFfYlklutN,+k WfY�iPk�Mr1Mi��,YFh1{[4�rrFM,k��«��**��«w <br /> SBMON 3 -To be filled out by contractor"decmtandnafwg txW': <br /> Tank Decontamination Contractor: ,J ~��,��j4 �a/��G <br /> G= >✓�/�� /�J/, ci �i/ zip 22L--Z 'd <br /> Addtsss:�� ,� 7 � � �'�— � <br /> t <br /> Phony <br /> Authorized represemtarive of contractor emifymg rhrough signautre below that the been rad m an apmved <br /> manner as required by Cal EPA- <br /> =e_ <br /> Naitk: /�11f�l/�signanae: t� <br /> Due C�" ! 0, <br /> rrrrr�ktrr+Y+twFMr+�+�wisr+MrRwi4rwrrYYrMFrt��M+F*,Frwt�r*+kIMMfRlrr F#r �#�t �'� <br /> SEC71ON 4-To be signed and dated by an authorized representative of the tree or facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> •� City:��/�� Zip: <br /> Address: - <br /> Phone <br /> Date Tank Received: -07 <br /> S <br /> CL <br /> Name: Title: �• S Acte �� <br /> ,w4�w+wwc�wwawrrrrws k•b*rwrr�nt,►�r*r�r <br /> rrrrrrwrrr +unM�M*""R*""*s'" -- <br /> EH 23 W (Revised 10/19/98) e 1 Post-it"Fax Note 7671 Daie ► <br /> To l From 7- <br /> Co/Dept GO <br /> Phone s Phone« ;y <br /> Fax a Fax M 16 S <br />