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' SAN JOAQIli N COUNTY PUBLIC HEALTH SERv xCES <br /> ENMONMENd'AL IVA,1LTH DIVISION <br /> UNDERGROUND STORAGE TANIK DISPOSITION TRACKING RXCORU <br /> .##s.•raaMaWMi�rtMwMMtR+I#*i4atFwi+YRrM#rya4wFw#k*tArsrsaw#R#sst#Dial'WiMM4wWiMiFM*4P+NF4fMFinyr►rtpetktesfiw#;�aa*easrw <br /> SEMION 1 -Public Iiealtia Services Environmental Health Division Tattk Trackiog Sheet aW tecompany wh tatLk affS,xed %iw <br /> its site Wentifieation number. The Tank Tracking Sbett is to be rehnnod to Public Health Services l?tivirontrlenftl Health DMgitr» <br /> yvftitfn 302y1 of acceptawt of the tame by the disposal or recyCiing(eeility_ The petit holder is t�esponsibie for aAsuring that <br /> Jus form is completed ttud retied. <br /> FACILITY NAME:_ <br /> FACILrUY ADDRESS. 0?4:$.5V _114M_42� <br /> TANK iD x#39 - TANK SIZE: t,,OV - —PRAVIOUS TANK CONTENTS: <br /> wrt}rwwk#r w,�rt##tMW M+FiFsMrtW*Ik+►;*;wFrti4k;#fss*t**i#isi#ttiMl�elluYM1FW*M(kIN1N*+MKk*WWM#llr+k**sr r st*#43#s+aA.Y1tWilu►hwr►a <br /> SivC'I'ION 2-To be filled out by tank removal contruder: <br /> "rank Removal Contractor: o4dvdy-e-4e jL \"";es� y <br /> Address: .j j + City: _5-1 Zip: ?,SOD-5-ak <br /> Date TanlcRemoved: Z 1hr[ 1 ,, <br /> �#*ss#*itlilR•a*sY•;Mlir##s#anal ikaaissssy*####scsisiik#####ieM**1MlkFw#4i*MRkNIYk#*�ihWIF+Fkkk#isMtiltrf#�R##*tk4#Krrwtav <br /> SECTION 3 •To be filled out by contractor"decoutatuinating tank": <br /> Tank i'3econtaminAzion Contractor: , <br /> City: Zip:_ "'2iJ. -- <br /> Autborized representative of contractor certifying through signature below that the tank has been decontantinated in an apprQvea <br /> nigroer as required by Cal EPA, <br /> Nasnt: —4-1 AtE Title: C47�(O Signature: J ate .I tis f v-1 <br /> raar*.WRs.**+***#1*##*rakt*l** *rtwWw�w*t**Wwwria+*M**+rx�rrtrt ****wws**+ #►�s#*ai***t**#i*w*Wr�w*kw*ww*ft,**w.rtfi <br /> SEC17ON 4- To be sigtred and dated by as authorized representative of the trtatintnt, storage,of disposal facility <br /> acceptiug tabic and/or piping, <br /> Facility Name, Gt.A " �- <br /> Address: t P O .��p City; 7W O&L Zip- ! 0 <br /> Dale TaA k Received:, _ .qC <br /> Mame: og Title: <br /> AtaF{a$W#A.r####ahrt*###Mssra}tlst#a.vRh tIMF klfk4FMfFy+kE##*ssRwa!'sk�asa*yew#4##►ssw**#tls#**#ASM.*+kktw+aNsss xrrrr#rMr. <br /> kl 23 046 (itsvised 10119198) Pace 10 <br />