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r <br /> SAN 3OAQUIN COUNTY <br /> ENVIRONMENTAL HEALTIi DEPARTMENT <br /> UNDERGR01M STORAGE TASK piSPOSTTION TRACKXNG RECO" <br /> rss»■r»ssrrsf»rswwwws»rswssrssxssr#rss»srsrr#*»»rwrws#rsrwww*srrsssrwwarss»ssrwssssrass#»»Tres#»*srwwrrrsss <br /> SECTION I-SIC Er"ironmental Health Department's Tank Tracking Sheet shall accompany each tank affixod with iu;site <br /> ideatitaantion n amber. The Tank 7rae.sizg Sheet is to be returned to the Fnvironmental Health Departrnontwith!,i 3�of <br /> acceptance of t is tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br /> and xrWmed_ <br /> FACILITY Na Nlt: A lex wt C c— <br /> FACTLI7Y AZ ARPSS,���3 _ �J i7 P 1 `, Ii •� �.J <br /> TANK 10#39 -� 1 T, 1M1 SIZE: f D-L-To PREVIOUS TANK CONTENTS; <br /> •#taws»srwrw.wss»srsrrrwisw«s#tr#rrrrw•awrss*ss»rrrrwwrrssssw•rwssr*s»r»ssrw.:rsss»sswsrrsssssw+rwwraswssii <br /> SECTION 2.. ro be filled out by tank removal contractor: <br /> Tank Removal Contractor 2! e— 01 ( <br /> Address: 677 C i IDC- ey�u � City: Lod l* zip: <br /> Phonc H:LZz,49) 3 rO Q^ 6/-2!S Date Yank Removed: <br /> srwrwwrtsswss-w�»-r'r+iww»k#»f»iir#Frawrwsss##»#ir*+..w's+�rwrr#r»»ww•ww**#*»R**rrwsairR»r#rr.»r»»w/rt►r►wwsr#»r»ir <br /> SECTION 3- To be filled out by con trs ctor"decontaminating tank": <br /> Tank Deaon:a:rtinatton Contractor' I co d 11 f <br /> Address: !P'7� S�— _City:L-e / —Zip: -- <br /> 175 <br /> Authorized rep resentative of contracts certifving through signature below that the tank has been d*6ontwnin <br /> j&adlzAn approved <br /> matmer as reqs ired by Cal EPA. <br /> 4 711 <br /> Namn:_ _Trtle: C'IQI�Sisnatore: ate <br /> +rwrs#**i»a►irarR»»i#r#iwwrlF#»1'#1 rrwwawwws*iir■x•ww.rrrfrr <br /> SE � rr�a►ssrs# w..*ssxs• ws afsr.r#»»#rr#+�r+r##s#»# <br /> SECTION 4•To be signed and date4 by an authorized representative of the tsea eat,storage,or dispossl facility <br /> sci eptmg tank and/or piping. <br /> Facility Name: S�,4n�-�z� <br /> r <br /> Address: � <br /> j`,ODD F SU(,-A- 4� _City,, <br /> Phone 01:(,l* <br /> Date Tarek Rec eived: ' �— <br /> �f r Date <br /> Natne: '' CMCJ CL Titlr.: t°f Signature: <br /> rsrrww..rs++ssssw»rr+•rrwrssss:csc.wwr:rrw.sssss*s»rss»s*»rwr+srssssssss.rsssserrrrrrr»»srwsrawrrawra»s»»ii <br /> EH 23 046 j.evised 1(116103) Page 10 <br /> Ed W13 3b:T T POW 80 '100 T 98T 892 GOE T: 'CN XUd -110 Ed8OHl W I t: WONJ <br />