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SAN JOAQUIN COUNTY PUBLIC ML4,LM$9R,*�i.I;5 . 4 <br /> ENMONI► MAL HEALM DMSION <br /> UNDE)tGROUND STORAGE TANK DISPOSITION-DUCKING RECORD <br /> r <br /> ���ilr�a##s**�*t��9ryry'klRttkfM►MWMMM�fWM[�IkNrtMMfMMMItYrt/iliit rtiklt 1lalYfli t <br /> SEC 1ON I - Public Health Scrvices Eaviroameaml Health Dlvhiou Tank Tracking Sheet shall accompany each tank atffueu wnr ` <br /> its site.ideutif ltlOn mmaber. The Tank Tracking Skeet is to be rete ned.to 1Pttblic Health Services Envirommental Health Dwime;i <br /> "WO 30 dav§of acceptance of tba tank by the disposal pr recycling facility. The permit holder.is responsible for.enswin$ttt;it <br /> hies form is completed and tents ed. <br /> FACILITY NAME LO ,�>:k S I P <br /> FACILITY ADDRESS: <br /> z ANK ID A'39- TANK SIZE: 43 MPREVIOUS-TANK CONTENTS: <br /> �.,�yvss***srw*■,��ewr*sw*x+�w.�Mw�Y�k*t�rwM**r***�rrrrrrt*M��*t��***s�**r:ry*f*w3a�r�f.�waw*w�rw+rwM***s*:s*a....wr.� . <br /> SIX"1IQN 2 •Ta be tilled acct by tack removal contractor t <br /> j ra.k Removal ComrActor: <br /> Addres5:_� j ! City Zip- <br /> Date Tann Removed: `� /yLa <br /> •+a+www+���***�»s*#*#*suet#*�*#isssyss:swa:swrwwYt;sits*i**s*»swwsswwrw�r4#wMk+�w#*4w+M*r.,wywp*wy*,sr4*ss��*„�r,�.r.,� . <br /> SECTION 3 -To be [filled out by.conttactor"decont2winating tank": <br /> „�-- <br /> Tank Decontamination Contractor . <br /> Address: 1V 15 CiryziP; <br /> Aurharized representadve of.contmctor certifying throulgh iignatttre below that the tank has been decontaminated in an appr.%k,t•t; <br /> ,a)mxser as,}required by Cal tPA. <br /> Name: �'" Yy� F Title: `-110 Sign3twre: "" 'J Date�'j U , �'�.r'.. <br /> i _.. . . — <br /> •k rO.iwtN+k#'*W+Mw�hWN'FN*�yc.ltk Mii�**#MsMlkrt##**#s#s*#4Msss�»�s:}!ae#Rf*w¢yrRtlLF+k4*##�#��d+F d+YA•k44s+F*t*Mr*-.KMwulnnGW <br /> I' SMION 4-To be x1 <br /> ped and dated by e4 authorized.'representative bf[hc treatment, storage, or disposal facil`scy <br /> f accepting tank aaWor piping. <br /> GtlefFacility Name: -4 4— <br /> . r <br /> address:_n> USC �g(re City:- I7 zip: ! e!__. <br /> Date Taa Rtceivcd: <br /> ttumc: w.z �c'R'{ wTitle:4Z <br /> � Signature: <br /> nary r art��#M kk ikJk k**ii 74Acw*fitr.ki.rY•rrl+4+t�e+e��#wi,tib*•t�w,eia•Y!*s+e4#.A+4.p+r#fi�A.+.k.l.#*♦*s i.k.F lMMW.Y4�r-w��e�a.:a k klk.4M W M'�www..w. <br /> 23 Mb (Revised 10119M) Page 10 <br /> �.:.�:=;=.ra-� ...._ ...�. ...,, ..:_ • ... ..... .. . __.__ s....�=- .. _� _ .rs..�.�- = `. _ r - .rte.t��r,. <br />