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C <br />RN�CES <br />PTBLIC1 <br />SAti JO:► `LiiN' C0Uon' <br />JOGI01.NN,1AD,'K-1 K <br />He„Izh Oir;(:r <br />p.v. Box `W) t (:(y)1 Ea't Hazelton Avenue) ! GaSron, Calierornia 95201 <br />(20;1) 463.3400 <br />UNDERGROUND TANTS DISPOSITIO`t TR.ACKIIdG RECORD <br />.att•.yRa t4itr r#eReaf WitRS Ra.'4 Rat 8RA artxyttsta Ritkaai l't r9 RtdEaaa sttw A'B*.*,,B Rataww—a,*t'!'1 i'aaiRstaa a+R tRB stla taRai <br />SECTION t - ?ublic Health Semi s T raking Sht-dt will acccinpan each .::nk of€axed with its site identDfiat tion number. TrtP <br />Tracking Sheet i<. to be returned to Public Fre: lth Services within z0 davq of acceatance of the tank by the disposal or reading <br />tie for ?risii-nng that this torn is `ompiet.d and returned. <br />tactlity. Tho pr.rmit holder is respors; <br />FACILITY NA E: <br />FACILITY ADDRESS' �yi_�TO� �°D Lc>>i f <br />!'.s..Nia ID x#34 - .�. Tank Description: 5-,000 <br />tttaBtRtstal.4iatts'sat RYOiRtta4Rita M'K♦Eta RRaaB^IRR eRtxyt4asf6aeaaetleYtR at4Rkrsfl.tkatt4.YRt tR4ktaR144't#xR ti Ma,s xsm <br />SECTION 2 - To be filled out b; tank rEniCvai cortrWor: <br />Trtnk R c n 10 W.11 Contractor:—F-Lwk—� �5 <br />_City: G Zip: C)S�A i <br />Address: 2. {�Y��-- -------- <br />Phone #.' ) 312— � � � Date Tank Remcvtd: �� <br />(_Sly. <br />iW•saRRRtRs'/6tlsatY.RRtaRBR$aasrdRRacsRa:Ri:atsateatsasaataaavaaea.ttdtttysaseast♦te4e'RtaRi.atRr►t'a4tRftlet4fsit <br />SECTION J !o be filled Out `vy contractor %Iecontt timid': tfiP.t <br />Tank DCcontit inination Contract= <br />Add!ess: <br />Phone #: <br />City: _._._ Zip:--------- <br />oltithorized representative of c: ntracto. czrti_`:t'd ')y Signing 13�:C'a t I :L' i iniC 1::5 tit:en dect;nla?;ini?ted iii 211 7prrt ved <br />maattcr as fectttir.:1 by rite Starz De,�aat rter.t =:€ heiilt ; ee.iti"ces. <br />Title: <br />Signature: <br />D a a f E a t i a R t a t i K 6 a a x �P ! a! a a �. a a r a? a..% a* a ff t• 0 R t a f tl Y a tl e tl$ s f a s a a t t t ... <br />SEC— iON $ - To be. signed and dated by an avizinrizea revrtse-rti,�c Ci rite treamient, stcrage, or disposal facility <br />accepting tank and/or pi - in,'. <br />t'i {aft -- <br />:address <br />�::l : �- - _- Zip: <br />Date Ta *'k Rc:t"'•'e : <br />Title: <br />t a e e d R a 6 9 v r a a 1 e e a /•t w s a a a a s K + a r s • K a. a 4 e a a r e e a•• a a s e O p t a r s.• s e a•• W a a i a a a i t a e tl K a a`• e e• t a s a e r a 4 t t 'r g a a 9 e! a t a e f W <br />EM 'L3 044 tRe. 2W3 !: i wp 1 <br />.1 �'aiY'on :;f fan ja:.qvc� : r,,:nn -t:'!• C-zc `e^'.:�i <br />