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?.' <br /> EwiRoNmEENTAL HEALTH 'DEPART <br /> SAN JOAQM CO"T Y <br /> Telephone:(209)40-M20 F=(209J 469-3433 <br /> UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD <br /> +�040­60__ . <br /> SECTION i - sic Environmental Health peoartmrWs Tank Tmcklng Sheet aWl armrnpaN each tw* alftxod wfth its site <br /> deWcntfon number. The Tat* TraOft Sheet Ic to be retumed to the Fnvironrhertw Health Depadment mqfitL,10 &q of <br /> ac=ptence of the teak by the disposal or rucyclN facility. Tha permit holder Is rftpcmbM for ermurIng that this form is completed <br /> and returned. <br /> FACUTY NAME: <br /> FACILMADDIRFESS, Pa cod. C;,LG5:LLP?6C:) <br /> TANK *39- 01 TANK srzF- t C>QO -PREVIOUS TANK coislmws: Gw^-QR0t_4"le <br /> A41 <br /> SECTION 2-To be MW out by tank rwmr.*W contractor <br /> Tank Removal Contractor: 111.4 C <br /> Addrnss: —Q-4 F. '9g. q�C 4k15_- j <br /> Pr)oM*4w.1-ja) S$l, -75wirp-S Data Tank Ram wed: <br /> SECTION 3-To be lilted out by cottirsetw"decontamlizatirtj tank' <br /> Tar* Decontamination Contvctor. M6 'Ser_-V1 <br /> Addmts: E, AL o r,1 n F'A fD_I_VD CZtr.L— <br /> Z2p,, <br /> Auftwimd rapnnwrtaMm of contactor cerWrig ftough mIgnature betryw that the tank has been dscwtw4tated in an approved <br /> ffmnrmr aq required 1by Cal EPA <br /> NarnwAN'4 Se,, 77- TMO." Sign3tum <br /> SECTION 4-To Be signed and dated by an autharl=d repmsonUV"of ft treatment,storage,ct d4posol Witt' <br /> accepting tank andfur pohV. <br /> Fadifty Name: z2A0_1Pj_&aL-CM to--,W <br /> Address: Aon)l <br /> Phone*. <br /> Onto Tank Recatmd: <br /> EH23046 (Rcviscd()7WJI0) 9 <br />