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Ll <br />SAN JOAQUri COUNTY PUBLIC HEALTH SERVICES <br />ENVIRO.NN ENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TAINK DISPOSITION TRACKING RECORD <br />a X------------------ = a.... ....aaxaaaaa.... aaa x]Czzaaaaxaaaxazxaxxxaaazaa a aax xxzzaxaaaxazzaaa xXaxxax z xxa axx x <br />SECTION 1 -Public Health Services Environtnental Health Division Tank Tracking Scree: shall accompany each tank mixed <br />with its site identificationnumbe:. The Tank Tacking Sheet is to be returned to Public Health Services Environrnentai Health <br />Division within 30 days of acceptance of the tato by the disposal or recvciing ;acuity. The permit holder is responsible for <br />ensuring that tilts form is compieted and returned. <br />FACTT i i :' N.3_My- D <br />FACTLI i `' ADDRESS: � F <br />=L�:i rJ `S9 - TA�ii� SiZ= �! 000 DRE'vIOL'S TANK Co C; 1�D <br />xXXXXXXXXXXXXxMXxaMXXxMXXXXMMMXMxxxxXxxxMxxxXxxxMMMMXMxxMxXMXxXXxXxxMxxMxMMMMMMX-XXMMM--M=XMMXxxxxxxxxx*M,- <br />SECTION '_ - To be P-lled out by tank removal conn. actor: <br />T ank Removal Contractor: <br />Address: P ©, !&n(,a23 b g _ Ciry: T-12Zip: <br />Phone = . ( 10 9 ) 6 (o 9 13 12 Date Tank Removed: <br />MxXMaxMXXXxXX*XXXXXXX—XMMXXxxx%x-MXXXXxxx-XMMM*xxxxXX--X-MXMXXMax-XXXXX—XXXXXXXM-%xx XX-MXxxx-Xx-MM-**,ea <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Conga= o.- 1 y ,(I - <br />Address: <br />.:CS S <br />w CS/1 - <br />�� CiLV: Zip: ?,T �Z 0.- <br />Phone =. <br />('`�L0 `�) <br />t�-(o "' (a 3-3 7 <br />Autt:or'zed re:)resenradve of conmctor ce:uryms throw^ signarttre below that the mnk has been decontaminated in an approved <br />wanner as recui td by Cal FPA. <br />%` e 5 %JZ Title:Signature' Date 1,l / � 19 _ <br />U 11 <br />%11 1 <br />*X----XXXXXXXX%X*a*MMa XXMXXX%XXX....*XMMXXX..*.*---X%Xl6XMMMXSXXXX%xXXXXXXMXX%a%MX XXMXX>CXXXXXMX-----M%x XJ4a <br />SECTION 4 - To be signed and date. by an authorized representative of the sea=men. storage, or disposal facility <br />acc.:ptin; tank and/or piping. <br />Facility Mane: <br />� I ,..p <br />Ci / <br />_95-3S-1 %0 M. <br />Phone <br />Date Tanis Received: <br />Nane: <br />Title: <br />Sisr.arure: Date <br />%ale*x MaXX*_M . x*XM*M***a aXMX%XMa X>4XX*%%xxxM%X%%%MaiXaexXM%xx:,.M:aeXa%Mxa=%XXaxXXXxXax%aa%ale:*ae*---%%M lex XM%ac%W* <br />EH 23 046 (Revised 9/11/96) Page 10 <br />