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PUBLY!14. SERACES <br />SAN JOA `UIN COi': "rY <br />JOGl 04NINA M.D. N. <br />Health NEW <br />P.O. &arc 2009 a (1631 a- ,t Hazelton Avenuc} s Rockton, California 95241 <br />(209) 46a -34M <br />UNDERGROUND TANK DISPOSITION TRACK3NG RRCOR.D <br />aaa•i#944'F;+s:ataasr$tFss+C;+EYaF.Ygsrarr$tm$t dsMata4WF8994+stsaass4q*AF*.*"'$$asxrs+i+ to rr$Asap <br />k arfNed with its site <br />SECTIGN 1 - Public Health alth Sew;cac Tracking Slt �";lll 3ccel, P2 e�; wi 1 In 30 d� of n cel3tarce of the rank tby the disposal or rec, The <br />Tracking Sheet i<, to be returned to Publac F �CZ'th _e, ✓Ic.. _ <br />fa(;ility. T?i8 pe -emit holder is reSl?Craible for , iriti' iiia[ t1i15 Ivrr� i5 completed and returned. <br />FACILITY NANIE-— <br />FACILITY ADDRESS- OEM> vI C i?- <br />i'?.NK ID x#39 _ Tank Description: =�04OOO, C=i/- L-LJ(2ki� <br />i <br />tRY+au$$asaw$$sa awess Yeticsyalk$$4rpMcWFas Y6•isE#'�+Y44k Atthea Aa6a•alspwiY#Faatr$Sstsl#+kapa$+Y#ra!$k+lAlltk'4p$F$Y$6f,Ef+Yi <br />SECTION 2 • To be filled out by tan% rer.;ov3r contr2ctor: <br />Tank Rtniowll Contractor: <br />F -i ► S e. ""' <br />City: zip: ��iagl <br />M d reSS: -- <br />1985 _ Date Tank Ren <br />�yAta$$YAf II'►6rEaAt$1ss4$!$ap+Y4'y''tCp4'`$rspp!$tae t4khr rq a"+Frrarq.+E ttdJ$a4'tl4tpsq'ACFa Z'p4$$=Kltl$$rRPy$p Aars E�af4a <br />SECTION j to be fiilel pili uj' Co tractor "r-?� Cor?Ilntiti2tiR� fc^. � <br />Tank Dccontannination C.cmar-wor: <br />Address: <br />Phone #: _) <br />i:v: <br />M <br />i r c7e it}i 5 - gr,:, 7�`.�C.-i :;'::lt t ie Tank 1:%s been decontamin,?t4'd Til an ]p fCVf'Cl <br />�vtnorized representative o. o nttwo. rartifled <br />manner 35 <br />rectu-,ed by the Staid Deal-TIMM;'i <br />Till �: <br />$ppss+sssrerwrrskw$gaasF:s#sEs$Feaarrtasaai.etas:Aaseae4r.r.atre�aaga.a+Ysaas4Fr as$aF aeq v$$raEd$$pea4'r$;sear $$tA <br />SE-C1ON 4 - To be sighed and daicd b --r,, authorized re;lrese-�ti+'� ci the tre��trjent, storage, or disposal f3cliity <br />F1 <br />acce.ptilim tank and/or piping. <br />Facili <br />AddresS: _ �__ _ — ��.�- _Zip: <br />Phone #:- <br />Date To b:Re:•.,`'e:1: <br />Title: <br />a i� a d p p t 4 r ..r r r� r q t.a a♦ .r ♦ a E• Y r F E t r a a a a t� e a 't a� q••+► s a O r p r t s•• E+ a• s r� e a a r a q .6 ♦ E• r K a r 6 e a M• a a a t q++ E a E"`'4 t a r e q+ a e e r d <br />v3a:. <br />Ex Z3 049 (Re, 2!001) wp <br />A:1MSIOq :if Ont j iswbt :'rcrr -ts'l C-rc stn^.:cs �/ <br />