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_..N JOAQUIN COUNTY PUBLIC HEAL'.. SERVICES <br />ENYMOWMAL EMALTH DMSION <br />MERGROUN'D STORAGE TASK DISPOSITION TRACKLvG RECORD <br />} *VS ilsws+,ktVrtrs*aws�ssssa#a###sar#**M7'sw#+M#ss**M** ts;tiwyrwwrraa*r.r.rrwWWww*wwrrwsswrsMowarrs*sr <br />SECTION 1 • Public health Services Environmental Health DiYision Tank Tracking Shat shall accompany each tank affixed <br />with its site identific3hoanutnber. The Tank Tracking Sheet is to be returned co Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tabic by the disposal or recyding facility. The permit holder is responsible for <br />ensuring that this form is completed sad returned. <br />FACILITY NAME: CHEVRON SERVICE STATION <br />FACILITY ADDRESS: 3C1 W. KETTLEMAN LANE, l.COI <br />TANK ID #39 - 2170 TANK SIZE: 10,000 PREVIOUS TANK CONTENTS. IIID GRADE CAS <br />y�rryr*rrwrr,Yrrrrarrarrrrrll,rinwrMwrMM M,M*WWMW ArMMwwwrwti Mow,11*wswwr**wWw�rMsr�rr#■rrrrr.rwrr,rw eswwrriarssra Mrrry M <br />SECTION 2 - To be filled out by tank removal contractor - <br />Task Removal Contractor: MUSCO EXCAVATORS, INC. <br />Address: 2155 HYLA PLACE City: SANTA ROSA Zlp: 95401 <br />Phone #: ( 707 } 579-O25Q Date Tank Removed: <br />ssssxssar•rrMrr�c##wsyaasa4sswswwwswswwwws*sws#*sMrsss##ty,►sssiMWr*ww♦MvMwr#wwwwr*is+wluaNsarYx*■:tiaMrrrs*rrrrx <br />SECTION 3 - To be tilled out by contractor "decomaminating tank": <br />Taak Decontamination Conaarton E C I E R I C K S O N <br />Addles: <br />255 PARR 9LVD <br />Phone #: ( 510 970-7402 <br />City: RICHMOND Zia; <br />94501 <br />Authorized representative of conaaaor cen4Ying through si,aar= below that the tank has been decontaminated in as approved <br />manner as required by Cat EPA. sem, <br />Name: <br />BRYAN H. MIUSCO Title: PRESIDENT Sigh IN . Datebtl �� <br />w* Mww M sry #ss}��**.I,v*w,YMw*,►w,kwr�«,p4s„*rr�is,M#*wr�wrwr �. � a�r+rwrr�rwws�*rw�.r**�..ww�wwa�w�w �M www+MwMw�MYM �*w r�,r* *�**+fi w <br />SECTYON 4 - To be signed and dated by an authorised representative of the trearmenr, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name, ECI ERICKSON <br />Address: •255- PARR BLVD Ciry; RICHMOND Zip; 94601 <br />Phone #, 551 970-745Z <br />Date Tank Received: ` <br />Name: <br />49 54TD Tido: Sti 71.��dr� $ignaruro: Mato al3f `fig <br />as a • ar oar agar a,� #a ra,as# 1�'#*M�M s s i*�►*#MM * M�ywwM dnY r. rrrr ici�io►#ir • r •r r. ww M r,M wf �h *`#s sa a+�,P * * M+M rw esu r* s �s*,s,Ma�#�r�M 7ww� • <br />ER !a 046 (RevLeAd 9111196) <br />Page 10 <br />To C1 69£L_9191OL ONI SZ101UAU0X3 ❑3snw 00:" NOW 86—Z£—nna <br />