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<br /> SAN JOAQtJI1"t COUNTY rVBLIC HEALTH SER,jLCM
<br /> ENY7,IMONl1 ENTAL HEALTH DIM10K
<br /> tmoERGROidNo voiurx T&zix DISPOSITION TRACKING RECO"
<br /> �.:saw,x�*sMk�crw�ur.rrru��w,r**r*+rr*#.s*.•wrNM��kwr�wewMW+��rn�r4w��,*�k*�+*#f+rs*#+#.+s#s+#*+++r►«�*r�rwWarr*wa*�rMr*rwss.
<br /> SECTION 1 - Public Health Services EnArournental Health plr►lsion Tank Tracking SbM&Dail accompany each tank affixed Nati,
<br /> its site ldentificadon number. The Twk Tracking Sbect Is to be returned to Public Health Services 1~nvitat�meatal Health Divissan
<br /> vv t_hLq 30.d��of aceepwee of sic tank by the di"gal or rtcycling facility. The permit holder is responsible for cnxurlsr� >�t
<br /> Otis form is completed and returned.
<br /> FACILI3`'l'NAME: Lo��L �—-
<br /> FACILITY ADDRESS:
<br /> TAMC ID x`39•, I q*' 1jANK 5IZ8:
<br /> ,.& PREVIOUS TANK C0NTFNTS:---6hn-6--�j.,e-2--
<br /> wr+#,►*rki+„##+#W#r*++##*#*+r+***kelt+*##+#`#�F✓#+�#i�M#I.#ir#4+4�k1,��Y�kY�Yr+Yf�Niik4��k•r�krM�k4�Y�kAiA�*�Y*a,t,lr#i+:#t*+##r+�rrgNtMN,K*�r�
<br /> SECTION 2-To be filled out by taak removal e/ojntracfor:
<br /> Tank Removal Contractor: .4d�-e DL. Q � -
<br /> Address: �.� q0M, City: Zip.
<br /> DO
<br /> 1ltrnr#- --�-
<br /> 0 '7� ��t'J7� Dau T&ak Reaaoved:
<br /> (�}
<br /> a.++.�rr:�r�4.►aWM##*4a*W�r�rMMr,Fw*N,#4+r+k+!**.4ikM�*,�*QFµ*µ#4kR+k,k,w*Mak##*,�*wwk+h�kyr+t{�*#�#*wr�t�ekR*#�.�.��V.�p*a,kr4'a•.+r..,.�a�-
<br /> SECTION 3 -To bs filled out by coutr$ctor "decontaminatutg tank":
<br /> rank Decontamination Contractor:
<br /> �+•�Address: City:
<br /> Zito
<br /> Authorized representative of coatractor certifying through signature below that the tank bas been decontw inated in atr approved
<br /> rnmwer as required by Cal EPA.
<br /> Lo Title: Sig�Bturc: 4Cl'-Daie_
<br /> r*K*s,ts•s}ss*�#*fi�'��%��P,k#*MW+kW�ltiwM�k,tW W,k$ik�k*#W#.1tw+►*+►Wt+#'*ski##,kW+k+kW.i,F,M,Y,M,k+F�r,kYNM*xrt#*+*#!*s*�#*x##+t#��Sv#���2 e
<br /> SECTION 4 - To be signed and dated by alt authorl%W representatlra of the treatment, storage. or disposal facility
<br /> accepting
<br /> �}tank and/or piping.
<br /> Facility Nawc: W495;j 4- 6A - 449W-1-
<br /> Addiess:
<br /> I'V .L, city.--7w w WLLr..� zip:
<br /> Dato Tank Reccived:
<br /> Name: Signaturc: ll> ^l ale_,
<br /> rruc�Mtl.,I�M�.RAc,k lints.fkww+��k*MKar,R###*+k*#Wr�w#�VW,�,YNrW�i,M.w Ncw WW1hM+Y,h�F k+p,R,�W*ih,k�*MMS*Ash?,11RwwwMS?!*v,rY+}s.ryest*w�t».+hrw�+.+o-w 4r
<br /> ER 23 046 (Revised 10119198) Page 10
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