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SAN JOA0111N C,U11Pr1T 1'UII1.1C IIEALTII SRRVICKS 1 <br /> MVIRONi11F,PrI'AL 1MA1.'1'll DIVISION <br /> UNUF;IMROUNI) STORAGE TANK UISPOSI TION TRACKING RECORD <br /> r{+#+##4}+#}########a##t#It##t#♦#############t#t####+##•###t#tt#t#t#tt#tt###t#####*#****��*��«�+�«**�*.*400 <br /> SP111101`1 1 • 111lbllr Itrahh Selvicrs rrrvitoosom till IlrAh DIvisinu Tank Tracking Sheet shall accompany each tank all xed <br /> Mill IIs Or Idrnllflrnllknl number. the TAok Ffarking Sheet Is to he relurned In Mobllc llealth Services F3nr1ronrnental Health <br /> 1►Ivlalrnl 1rltlrlrt_10 dnr9 of Arr.rrt:mrp of the tnrsk by the dicpmsnl or recyrlins faculty. the permit holder It teaponllbie for <br /> rnsuling lhat 1111.1 fn►m 1.1 colmpleted And reurrned. <br /> FAC:ILIFY NAM11- Sun West Liquors IsX.A. # CAC 001359464 <br /> 2449 W. Kettlerna.n Ln. , Lodi, CA 95242 ; <br /> I'Ac:IVII Y AIMP 17-SS: _..._.-_-----.---__.-�_.__---- - ---- —.—�__ --- <br /> IMIK IU #39 - �J 'TANK Sum.: 10,000 ga-Is•PRrmotls TANK CONd'EN'rS: unleaded gaanl3nP_ <br /> 1st.++}++F++4#�#+###+#####++########+###F######f##�####################*##t##•tt###tt#t#t##*##,��*##+��####�*• <br /> sFf"I I()N 2 - '1'n be failed out by tank ttmovol contractor: <br /> lank Prnmval C:mwortor. Jill! Thul"Ve 011,_111c. <br /> Addirvi: 3131 N. Ueckmaii lid./P.U. Uvx ,35Gvd�_ CA Z . <br /> 95241--0357 i <br /> 11li(me N: ( 209._)_3613-61 F/5 I)a1e Tank Removed: <br /> 1r++►+++,a++a+#4+### +►#################♦#####4###+###t#t####R##4*## tt#tttt#t#4t##tt#####♦#t4*1�##4#4�4*�� <br /> SITUI ION .1 • To be filled not by con(tactor "deconln"Annting tank": <br /> lnnk Pecimimminm►Ioo Contractor- J1.11 '11101-)►e Utl r L1►c. <br /> Adrbr.1.1: 351 N. Becluuan lid./P.U. I)OX 357 Caty: Lodi t CA Z)p;95241-0357 <br /> 209 } 360-61-1`} <br /> An1hool7rd rrlsrr.trnlative of conlractar cerlifying through signature below that rhe lank has been decontaminated In an approved <br /> t►Innnr.t a.1 rrllnhrd by C_al VPA. <br /> Sign <br /> atare: le <br /> � �++ �+4�+ t#+#+# +a+ r ## t####t# # *# �t+rt# a#tt###fit#t#{'+**##♦ # �#ttt# ## # � ####A* <br /> 1al)�C is tree otga�r ��y ar11 �}yr1��o�ar�iort va�rors a troil cue f�ver,�g�o ���t��r ��ee�. . <br /> SF C:1 Ft)N d I'n he st rrrd and rFalel r an still in <br /> �e reprs►�enla Ire of the treatment slo a e or s s acll I <br /> acceplItig lank and/ot piping. <br /> 1 <br /> 'mrlllly IJnn1r:- Scloll.l.zer 5Lee1 l're►ducl.s ,� i <br /> (tcrrlcho Cor•dovar CA <br /> Idrlrr.t.t:- 12000 F'c�.lsum 11.10. (11y, Zipt 95712 <br /> 916 965--/1910 r <br /> _ _) <br /> 1n1r tank n4;rived:_ _/� � ---- <br /> rC4S4.P�,e� ,sem <br /> 'an _ -1W111e: ✓ Signa- re ate <br /> r.. ; <br /> 1+++++#t#+} 4+•♦#+###F##+kM�######+#t#r##*#++########*###*}#####tt#t### #*#tt######t*#♦4#f##4+#*�+#*#*4 '. <br /> �l 2J Ib10 (Revised 911 I/9f►) rage 11) <br /> i <br />