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MI:1. ��. 17�� 11Cli-Ili ,•�_ <br />. JOAQUIN COUNTY MBLrC AZALT- .ERVICES <br />ENNMONMIYTAL REALTH D1VMOK <br />UNDERGROUND STORAGE TANK 01Sp ITION TRACIONG RECORD <br />s*Mena +rago M*a***dM*arasawna1WM1Wq*A*0s <br />SECTION 1 - Public Health Service FAvtxonmcatal Health Division Tank Truldug Shect shall accompany each tank affixgd <br />with its site idendficadan number. The Tank Tracking Sheet ism be returned to Public Health Services Environmental Health <br />Division within O-4-14yl of Accepcsmce of the malt by the disposal or recycling facility. The permit holder is responsible for <br />ensuring tbu this form is completed and re=3zed. <br />FACILITY NAME: CHEVRON SERVICE STATION <br />FACILITY ADDRESS:_ 301 W. KETTLEMAN LANE, LOCI <br />T,k.TK M #39 - 158542 TANK SIZE; 1,000 PRE<1'IQUS TANK CONT;NTS. WASTE OIL <br />r+rrnrwrA#+rirWrr+arryr+++siert•ssrywylrr>rwrw�rrr+sswsssasa <br />SF,CTION 2 - To be dUed out by tank removal coatrsMr. <br />Tank Removal Contractor: m U S C 0 EXCAVATORS, INC . <br />Address: 2155 NYLA PLACE. City. SANTA ROSA <br />Phone #: ( 707 57 9- 0 2 5 0 Date Tank R=oved - <br />0 ***&*a* <br />emoved: <br />Zip: 95401 <br />♦rs*a*++ wow* rr+wWWirrrirrrwrrrrrMM <br />SECTSON 3 - To be filled out by coMmaar "decontarninatia= tank": ' <br />Tzak Decoutaminad OO Contactor: <br />Address <br />255 PARR BLVD. <br />ptione +it: ( 51 O } g70-7asz <br />ECT ERICK50N <br />City: RICHMOND Zip: 94801 <br />Authorized representative of ===or =Zdyws tbrough siP== below that the tank bas been deeont=i=ted in an sppruved <br />manner as required by Cal EPA- l <br />• BRYAN �1USC0 T1dC= PRESIDENT + Darc <br />N3=. AN H. <br />•rr w 1 � w r • �►yla�l sir * 1P+*s+M�� ra r lrrraralr�wr ranutM�tsaRlssy f IrRI� awn*M asNarlii W rrW71J1N11 Ir s ssss�si «717RM • w,pMaMaraW iM Ill W al sa s+z s <br />SECTION 4 - To be signed and dared by an Authatized rtprsentatire of the trea.•-r= sto:3ge, or dis�esal faGiliN <br />accepting tank and/or piping. <br />Facility Nzmc: E C I ER I C K s O N <br />255 PARR 9LVD. City. R7cHmnNn zip: a/.Ani <br />phone I, 510 970-7452 <br />Due Tank Received: <br />Natnc:<,� I Tette: ��s a sig;tauuc: ` Da:e i5%3r& g <br />rs+��+��*�� •T'1'My"1'M�*+I�+�t�*rrt Mr •� �� Inw wl�+MwM �Mg171Y>wY Ir+�*w+,rsa+�rrsrry�wrss+lrs�r+�rr�...� wa�ws��+sr+aal y�ww *r wr <br />EH 33 046 (Revised 9/11196) <br />Pap 10 <br />ze 9 d 6851.ra1�it0t SNI saotdhd�x oasnw zs:et Now 86 -TE -find <br />