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SAN.IOAQUTN COUNTY PUIBUC HEAL'T'H MvICES <br /> ENVMOKMFNPAL HEALTH D VISWR <br /> UNflf;,RGROUND STORAGE TANK DISPOSITION TRACIaNG RECORD <br /> rrrtrarrrrarrrrrrrl...rl+rl*�rt.irrraarrartrt.r►rrrlrsrrwrrrarrirrrartrrrrarrrrrrwirwysa+•ar►+rpy�rrarrlrrr..r <br /> SECTION I - Public Health Services Environmental Health Division Tonic Tracking Shat shall aecnmpSay waft tank afftcd with <br /> its site identification tittaibcr. The Tank Tracking Shaer is to be returned to Public frith Services Envitormentsl Health DivistOn <br /> w[tWa 34Al"of accepntnce of the tonic by the disposal or recycling facility. The permit holder is rrspona.lc for ensuring that <br /> thin farm is cornplctcd and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: -" (c, —'synAt^ <br /> WANK ID X39 lei TANK SIZE: 10,6RI PYIOUS TANK CONTENTS: <br /> i'tVtelt?l l-L{,t - <br /> *Mae"We" a.■lrrrrr.. rrr.rrrwrrrwa!!MlrwawsrwwlwrrWrrsrtrrasrrrt*rwwrrr**rr�sfwwrwgwratrrraaaa.. <br /> SECTION Z - To be filled au�r/by tank remonf contradar: <br /> Tank Removall�Contractor: <br /> Address: <br /> Phone t': Date Tabic Itetao,►ed: <br /> •,�y*ar.rr..r.rrrrr....+r+r�nr+wwwrraa*r.arrrarrs..rarrarllrrrrrrrrwrw...rtrrrrrrrts..a.rrr rr+*r++arrr.......... <br /> SECTION 3 -To be filled out by coo near*'decnnt=WAad=q tank": <br /> Tank Decont2minittion Contmcror-. -Kc—o <br /> Address: ,_ 1O tJ C: L,�, rz�44 City-- Zig: r <br /> P3tonc <br /> Audiorized representative of contractor centifying dirotigtt sign me below titre the t=k has been decautaz Lied in an approved <br /> manner as required by Cal EPA. <br /> Name: L�.J Tele- 1 Signature- Dw <br /> •+arr rrrrMrrrrrratfrrrrr+rarr�w+r.rrlarwrrlr!!*lrrlrM+rrrr•iarswrrry�rs*aw/slrMryw+w*4V�'ww�lrrMPsrrrr* <br /> SECTION 4-To be stgued and dated by an audwiz>ed representative of the tsesttmcnt, suat•sge,or dbp=A fatality <br /> i aceeptiag tank andlor pipitig• <br /> d <br /> i Facility Name: <br /> i' Addresa:._._,L�r?- - / � {_ _ _Cfry: Zipr L:F1 4 <br /> Phone y: (�}l ) U 3 I f y 90 <br /> Dam Task Received: <br /> Name- Title: Sigpantre: Dw- <br /> rrrr*rar..rtswaarr.r..*rryrrrrrrtrtrayrsrMrrrarrrar*yw*awawrrws►wrrrawraraa*rrsrsrrir+rrr.�r�sa+rrywrisrar <br /> £H 23 046 (Reviser! LOAW98) Page 10 <br />