Laserfiche WebLink
JOAQUIN COUNTY PUBLIC 1MALI ZRYICZS <br />L-OrMONII OTAL MEALTH DMRON <br />UNDERGROUND STORAGE TA>`.YK DLSPOSITIOK TRACEING RECORD <br />■ aQ s+NwMMiw�.#■bwiirl��Y�IWYry7�a.*N,��I,Ia,MYr,7Yraaaaaqarwl/aaaysat�rr,�sssisa�aaf��esx <br />SECTION 1 • Public Hcalth Servim Eaviroamental Health Division Tack Tracking Sheet shall accompany each t=k affixed <br />with its site identificauoa Lwrtlber. The Tuck Tracking Sheet is to be returned to Public Health Services Eavironatearai Health <br />Division within -3a gays of aceepcacce of the uu* by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and retuned. <br />PACIUTY NAIVE: CHEVRON SERVICE STATION <br />FACILITY ADDRESS: 3Q1 W. KETTLEMAN LANE, LOOI <br />TANK M k39 - 2174 TANK SSE; 10, 00 0 PREvIOUS TANK CONT&VTS: PREMIUM G A S <br />rMr*wwiwWUW*wwwwwrAwrl♦*wa*aMaaawaaaar*aWYw*boons • No's ■asstowsrWa*riaWiaaamWaw-aaiaaa--*am" **a*arm W*awwee aa**** <br />SECTION 2 - To be (inert out by tank rtmoval contractor: <br />TmkRemovalCamractor: MU5CO EXCAVATORS, INC. <br />Address: <br />255 PARR SLVD <br />Phone #- ( '101 5 7 s- 0 2 5 0 Due Tank Ra=ved: <br />City: SACRAMENTO Zip: 94861 <br />•yrwarwwawaaaaaawaa.r■a-wwwis�w+twrrrWWWW*m*Am*a*arrWa+rMNow w,00*amt#*sss:asass*swsaa.awMWfw***h <br />SECTION 3 - To be filled out by can=cmr "decontamiasatiag ti a `- ' <br />Teak Decontamination Contractor: ECI ERICK50N <br />Add= 255 PARR BLVC. City: <br />RICHMOND <br />Zip: 94801 <br />Phone K: (51 0 970-7062 <br />Authorized representative of contractor certifying through signature below that the cants has been decontaminated in = apprnycd <br />msaner U requircd by Cal EPA. <br />Name: 6RYAN H. MUSCO 'Yirlc: <br />.) C <br />PRESIDENT_ _Sl ]Oat LL �I <br />araayy*aaa**wa*www*swwwwwwww.twaswa#aasMa**+►ra**##wsrww#awwwwwwwww*wwwwwrw*w.rala+wrMrswawaw#aR#Mrww#a4wA�+r7hr <br />SECTION 4 - To be siped and dated by an au€horiad t-epressentarNe of the mac. storage, or disposal Facility <br />accepting =k muter piping. <br />fwWgName: ECI ERICKSON <br />A&Irm, 255 PARR SLVO City; RICHMOND yip: 94801 <br />Prions f:510�) 1 670-7462 <br />Dau Tank Received: <br />INam< Dfv( o 51rD <br />*wawa+�I�agiw aa# as ■wsawssa a�rsarwwaa+tssf#aaswa ■swaaw w*wwta*aa asarsw*w rr wwwaras ww tis.stsw�.w wy4awatrawa aaa # #s * <br />rale: � Slgnanae: G��r Date, <br />el3i-lam <br />ER 23 04b atevised 9/11/96) Pqc 10 <br />�e�e.-a-+--�,�.'.-c-Sr^••-----„•,•,• ti�..�.�.��-..-• ,-gip;... ... ...^-.....-•..��--�..�++r+�•v. M+,-"---r.�-�..�.....�.���- <br />Qi'd .68£LS4S404 SNI Si101ti,�tr�}{� 'OoSrSW £s=AIC NdW 66—SE—nf1fJ <br />