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SAWN JOAQUIN COL-N= PUBLIC HEALTH SERVICES <br /> EN—MOI`+-ME'NT.kL HEALTH DIVISION <br /> L-vDERGROUND STORAGE TANK DISPOSITION TRUCKING RECORD <br /> I <br /> I <br /> KYicxa�:st�v,fia�i.�r,�x��tYxasar}ray*arm*x»xai�isX�ar:aa.x�iye*iexi�a x*���i�� ���exa..a.x,:xx�F�ic*�a.y,xa,a,a�Kx�r ir�xasxr.f�.}x�ia�.r.xxi.�i.}�w},.x <br /> SEC ION 1 - Public I?e:lth Services Eavizonmeatal Health Division T Tracking Sheet shall acconnany nc'a tank a*;ixed <br /> with its site ideatincation at her. The Tank Tracking Sheet Is to be re ed to Public Health Services Eav=roamental He <br /> eatance of the tank ay rhe di<-nosal or re c?ia; facility. The permit holder s resaousioie :or <br /> Division within 30 days or acc <br /> easuring that this form is completed and returned. <br /> FACILITY NA'-'ytE: S S 7A A Xkl l} <br /> 345 Yosemite Avenue, Stockton Ca 95204 <br /> ,7ACILI T Y .ADDRESS: <br /> TANiti ID .#39 - T.-%.,N-K SIZE: 4, 000 —PREVIOUS T,.NK CONTENTS: gasoline <br /> lxxx }la.is[9[x�al[YI.ilxxxT"Ar:}yxxx.tTtaii.Xits}Yx][x]i[,It lax Xisax xxx#x.I%.� ax...a..Xyyxa]1>•.XYsxxllr>y.yxxx.:x}rxxi,..s:}.sra.x xx}.a. <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Advanced GeoEnvironment 1, Inc . <br /> Tank Removal Coorrzc:or: <br /> 1803 West March Lane suite a Stockton Z;o: 95207 <br /> .-address: Gty. <br /> Phone : ( 209 ) 956-0264 Date Tank Removec: <br /> XYY.iL}Xaix}}}}xxx}}}}}rrrxx}.j...}XSI}Slrxxxx}:x}r xxx xx><Tt][]s»�l.1. .><>• xxa.}x9.v x..Aar <br /> x..rXrrxxxXXXXrxx.,..-----x <br /> SECTION 3 - To be Ili ed out by contr c-or "decontaminating tank': <br /> Tarek Decontami_aticn C�;r:t ruc:or: Advanced GeoEnvir nmental Inc. <br /> Address: <br /> i 803 West March Lane suite A C:7r: <br /> Phone .T: ( 209 ) 956-0264 <br /> Authoriztd :e^reSea[at2ye OT CDntI2c-or certifying tlrcuga s;t,T+._.arrtre be? W Lct •tee tank has beta decom *-' tale^. A an aproved <br /> -anner as -e wised by Cal -PA. <br /> Nie: Tire: <br /> { ignanure: Date <br /> rX.{x.kxi.a.>'.Iliar'...aK.Xf...xrr....Flaa[�1i..4t.ItXxx xxlkxa[y.X lit.itrl,rx..x]..X}y,sx }xf><><X}'a[Yi�l[�xxr�lf}cxi[Yxxsa,irXxa.xa[}}x}�.xat a[a[as aixf+r a.><?� <br /> SECTION 4 - To be signed and dated byn aut.borized representari e of she L—earment, storage, or dis-ces:l faciiiry <br /> acceadng t:^ andlor piping. <br /> West Coast <br /> raciiity Name: <br /> 5100 Taylor Court C; Turlock 95381 <br /> Address: <br /> Phone .T: ( 7n9 ) — <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ...........a.... ............. ......l.a. x....w.r—.r»----:a.r.,.xxxr.�..x.a,R.a <br /> EH 23 046 (Revised 7110196) Page 10 <br />