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%./ V <br /> SAN JOAQUIN CDUIYTY PUBLIC HEALTH SEMMES <br /> ENVI tOMWENTAI,HEALTH I)MSION <br /> L DIERGROUND STORAGE TANK DLSP0srnoN TRACX3N(; RECORD <br /> � �+i�lirrr.ir�ii.ijr+irrrrtliira►lrrarrrairrvjaM+j rrriwairra.arrarrlrwawrrararrrra <br /> y Nrrrrrrirr;res awrrrwai+rr.r <br /> SECTIr?N f • Public Meaith Services F-RvironntenW Health Division Tank Tracking Sheer shah accompany euh tQnk affixed with <br /> Els site Ideatification number. The Tank Trac)dng 5hett is to be rentrned to Public Health Scrviczs Eavtrors:naarst unkHeaa Divisiondwit <br /> *9hhLLQ-dAYg of accrptanCe of the tank by the disposal(or recycling Cacility. The permh holdtx �res <br /> this form Is cotapietcd Md returned. pottsihle fare ms$ that <br /> PAC1LITY NAME:_'�rP—A,2,, P41? <br /> FACILITY ADDRESS: c3 +4Ct <br /> TANK 10 r39 _ ! �C WANK SIZE: IO DDC PPLEVIO S TANK CONTENTS:fT LA&6 A) A— <br /> •r a!i it res,tri!l4iiry�;aairy�.iilrrtr*yxrirtrrrrs iilrlarirarrr*lrarrrrrtrlrr�rlylriwrrrrl�wrywrtr`r,yw�t.a►.rrr <br /> SEC'T'ION 1 - To be filled out by`Lailk tetnovad contractor: <br /> Tank 1lermnnl Contractor- <br /> Address: ?5:a btu!-�C'� (.��/ City:`]G�1�a4� _ C� <br /> -�" Zips <br /> Phone i<: � ) a-�c: � Dare Tank Removed! <br /> iti+wilt,lrlrrtria+raaarrwrrrirawialirr;lrtlrrrtai+trari+lrirrtwwra.rrrawrarrrlat►rr.l.ar.rraartrrarrrlrrwirrr+aw <br /> SEC77ON 3 -To be filled out by contractor "deenatandnating.tank': <br /> Tame Decont2miaation Contractor: KF E ] ( <br /> Cary' ��- • A Zip: <br /> Phone I- <br /> Authorised representative of Ccnu tctor certifying dsrough signature below Ow the tank bas been dee <br /> Winer AS squired b Cal EPA. oatami rt d is approved <br /> ,— � Siytatttre: Data <br /> 344.6*iril+rl++rraaril�ir++rrrarraarr++rrarsrai�artrtrrrr*rtrlrrrrrrtes,r*•r+rrrlrr+rrrlr!!a*rlwaalryaa+++rt+wrrt <br /> 1$C]'ION 4-To 6e signed rzc ,fated by an authorized reprementative of the tryst <br /> scent,stor or d' i <br /> accepting taalr.and/or piping. the <br /> �:���' <br /> pticillty Mase: <br /> Address: _ - Z <br /> i:iry: <br /> Pltoae I.- <br /> Date Tank Received: <br /> Nims: Tide: —Signature: <br /> bace <br /> iiriiiaa+r;a++iii++i+itaa+;.,�r•rr/.rrrraar.r*rirr+r+arawrsraarrrr+swrarrw.rrrrraaar...rr*�ryry,aaawra.aaa <br /> liH 23 0463 (Revised 10/19M) p 10 <br />