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5-27-04; 8:43AM; ;925 557 7888 # 32/ 34 <br /> 03/0512004 13:59 2094683433 FIFTH FLOOR PAGE 34 <br /> SAN JOAQM COUNTY PMLZC MALTjff SERVICES <br /> ENYZROMDENTAL 119ALTH DIVMON <br /> UNDERGROUND STORAGE TANK MSPOSMON TRACIaNG RECORD <br /> y##�hkskxF#.WYtiuic+kkN�tk+k#*N4+�RtxmankMNkaexnRrikNlsed:#«kk•F'hbaPPx*«Mk#*Ks#s###�eaS,+��k+krk#Ycfl+kik*sWFAA,x#Mk•6•t#NNa:awq**#Ac�e�tCk+k«��ksf$e <br /> SEC3`XON 1-Public Elealth Services Et,vironaneMal Health Division Tank Tracking Shcet shall accompany each'taaxk affpmedwith <br /> its site Identification number. The Tank Traeklug Sheet is to be returned to Public Heallb Services EnviroMnental Health Division <br /> within 30 dsys of acceptance of the tank by the disposal or recycling facility- The permit holder is rUP=ibte for enstisriaa that <br /> this form is completed and returned. <br /> .FACILITY NAME: 'ge e. -* —CA/I <br /> FACILITY ADDRESS:_ 18-1a CP Y �., c�c.�hi (',�► . <br /> TANX ID#'39-D a TANK SIZE: JOD Qom-. PREVIOUS TANK CONTENTS; ,/ <br /> 'v�e�«si•,rF.tArY�BaFAsx*«k�xx«ya�kkxacar3#*+kx.ktxeNR#Nr*w*E+*a+s#�«*F�*.#�aM**k*kY**kk*i�N+r+Mx*'�'N**k„**riF**kk�N�**xwNNe�N* <br /> SECTIM4 2-To be filled out by tank removal contractor- <br /> Tank Removal Contractor: j�F C:2 <br /> Address: 255 p,4PZ P, SL. City: I14C.FF�,JUNO Zip- <br /> phone#.- (-57D ).2357- Date Tank Removed- <br /> ' Mb*�g#*�x�reVaNkk�is+k+k�e«txYei•ir�eF�s#awaet+�t*�erasK#*ayat#toY�+M#4x*#MK+*#*M+Rkstr#*ok*s#,gE`N#k�kae�cs�s{syr##;�k+kuir�t�t�,t�ek*rkllc*ktu <br /> SECTION 3-To be filled out by contractor"deeontamiva flag tank": <br /> Tank Decaat~amination Contractor: -14'cti1 Yi M <br /> F <br /> Address:_ 5 - P-7 oyla c--p l4 f+L`f city: C-Ppevi'mo Zi !q4--52-0 <br /> ??hone t#: <br /> Authorized representative of contractor certifying through signature below that the took has been decoutarninated in aro appmved <br /> manner as required by Cal EPA. <br /> Name: Sigoatum.. Dare <br /> !t!«;+T«Nk+YWTTt<x W iieriF MY•W4s.p k•M+«W♦k•s xynkYc�6+hkiW 4legsk4«N«eY**+oe,kaex*fief W� Neri7FoM##�$daF k3#+dM M"�'�a'x*'NNSM7FNN#;#«e[.k#&#�$kN+k« <br /> SECTION 4-To be signed and dared by an authorized representative of the treatment, storage.or disposal fatuity <br /> accepting tmk.and/or piping. <br /> 7Faciliry Name: <br /> Address: eity: tc "0> O Zip: a-+00� <br /> Phoria//:(� �3✓ ,3�3 <br /> Date Tank Received: <br /> Name: Signature. Date <br /> �#K+#ie%ea**#k x#xai#**#xx##k ax:t*«**�x x�F**3#s#�+ekai*ytnkx�**#kk«**Nash#*.x u#9+��'k#Q11e1ete*7{/fp�s•kk�e*7jt#h�Rx#*x W*�***x*k«ba�ks <br /> H 23 046 (Revised 08113119) Page 10 <br />