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ES <br />PUBL1(!H.-EALTH SERNIC ' <br />SAN I AQ iN C0U',-r. <br />JOG1 hiit.NNA M.D. -i' H. <br />l,h Offi <br />her „ t,tV <br />At?. Bo. -c 2009 4 ( i631 Eqpt Hazelton Avenuc) C:i1i-fonrda 95201 <br />(209) 468.3400 <br />UNDERGROUND TANK DISPOSITION TRACK]-ZqG RECORD <br />ARQ•ydQe9Qaaaaetssa••OSta Sffi$tQtt+ia arc sydR'sal d**** *4'f#4****eaa 69****** *I V4$Q#uera* de f.Nr Qas MW ata:apt las 4#aa Ace# <br />SECTION i - Public Health Se: rices Tracking S;trzt wili acccmp3ny each trnk affixed with its site identlfiattion number. file <br />i rat::{ittg Sheet to be returned to Public Fie: th Se: -rice, witlii____ M da?4 of acceatarce of the tank by the disYosal or re:yc!ing <br />tacaility. The permit holder is ;espor.s;ble for :n5lie iii that this torr is cornplet!d and returned. <br />FACILITY NAME: � E U S r7-�— <br />FACILITY ADDRESS: <br />TA.NK ID 439 - Tank Description,: (O00 CL4 t..tp d__ _ <br />syr arRsess:+rOQ#e8't QmssttAeAttlQaaY:Wi*:aQFssatL♦by Qariaca eQsaraaew.4il Ra OstrtwFd Q,e#4Wd'#a Qta taa31dc 1t 1#pQk DAa,a rbi <br />SECTION 2 • To be filled out by tank <br />Tank Removal Contractor:. F --L" <br />r. <br />Address: Z_I1.�"L���1�- �ir1/D , -- .. --- City: Zip: <br />PYione #: (_ ) 312— �j Date Tank Re'rC^�:d: � I <br />Awd#a+1dt'tQssV 6aaas$Aasisam$Q►4'Ps'k4e�af E'lgy.:waaa AedRs#ee..a#esaay+ea.[ta8#yvad4a yAd9Qel�dfaKY dKs ♦►,.►'a'd•Rsea #ts s4s <br />SECTION 3 .!o be MIC4 Out u}' ^,Q?ltra%tQi R:lt;t oR�1II1:I12tt^.� tar :•: <br />Tank Decontamination 0rntract0f: <br />Address: _ - Ci;J: Zip: <br />Phone <br />' ,horized re resentati�e, of C'.3:ntracto. c-ertulied �?� $' P. iii4�' !J:lC'= : `.a Y t ,e tank 1;.^.s tieen decontaminated in 211 apjiiCVetl <br />Apt, ' <br />ma nncr s b 5 J C,,.` Y o`.Realm Cr.iti'iCeS• <br />,�, � fc.ctitir.'1 by ttty .:...,C DepbSYi.i::1-t � <br />Signature: <br />Title. <br /><##Qaa*Q.lewe>s stir#seQgatt#s4Wx*.r44 ##tat 4sa eaA+aase4ar.. ..•wt'ee Aa asrasasatR acs+Mesa«$a satAi Raaeya as to RV YISa <br />SE!:FION 4 - To be. si^rlCd and daied by u.ttlloriz+'j rZpre3e tii'� C" the treatmient, jtGra£e, or disposal facility <br />r <br />accepting mrik andlor pii ing. <br />:address: _ — --- city: <br />Zip: <br />Date sans; Re::i�'e:i: — —.�_• ._ <br />Signature _ _ r Tide: <br /># a• e d a E##.�. e ... e.#•• e♦ a a e y Q i a s• e+ e a 4• e• a s. e• •ase .sae • s c,+. a .. . y+ x a a a a i+ s a s e a a s• a a+ a e e e a s a s w .r + g a a t e#. e a e� y <br />pia <br />Ex 23 C49 (Re- 2101,9?) wp ` ) <br />A :;f !an j<Vs1W'c1 :'•;v n -t:'Y• C-rc `ent;�s \/ <br />