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12/18/98 FRI 09:33 FAX 5106096304 RII. DESIGN GROUP RILL. Ph19LurtA Loull <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRAC 93NG RECORD <br />._...,W.r..+.rk....."........,.... r,aae.sr.r.wr.*..,w.www=..,aww......."s."ir,1+ww,.r■w.ww»wr <br />SECTION 1 - Public Health Services Envirowne ral Health Division Tank Tracking Shit shall accompany each tank affixed with <br />is site identification number. The Tank Tracking Sbeet is in be neutncd to Public Health Services Envermmearal Health Division <br />within 30 days of acceptance of the tank by the disposai or recycling facility. The permit kinkier is responsible for ensuring that <br />this form is completed and returned. <br />FACU=NAME: PckRQorr SY1EIl y <br />FACILITY ADDRESS: 1313 C 4wr 1Ait% k <br />TANK ID1139- 0� :C / TANKSIZE: 10,ODD PREVIOUS TANK CONTENTS: 6ASowfic <br />SECTION 2 - To be filled out by tank removal eo`ntr-actor. <br />Tank Removal Contractor: k • E C k.,tr' is <br />Ate: lqOp OLID CAr"+Cjo RP City: N&AvieuPhe": Q 132 b <br />Pbooe *: (91(a ) 11 b -SSS 8 Dare Tank Removed: <br />wtr+�rtM«rrtovsilrrt"�rt+rrrrrwrar+isk+Maal+rtrtrt�Frtart�M4tr+w Wt+Yrtt+Yr+er#srt�Mi"r4rrrt4+�F�krii+w�r.FrtrteV'w�kisw4n*rtWrrtYrt+FN�w <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />C <br />Address: ` q$o X((%4 kk4t ST. City: OakIrk no zip: <br />Phone #! ( 51-10 ) f033- 0,316 <br />Authorized representative of contractor certifying through sigoatn= below that the tank has been decontaminated in an approved <br />manner as required by <br />Cal EPA. Q� <br />Nrme:- —�e Title 6�fl.�L /1.JQlgvatrQe Dateii _ " <br />.rtrtrnr«*rrrarbrrrert+rtV.•.raswen+rM"eswrsaw.r+w.+rtw►�M+++wen+wy+.+9.rt+rt+r«r.sir++w.rsr.rtwynw+rM.aar.rtrtrr«+rw+► <br />SECTION 4 - To be signed and dated by an authorized representative of die treatment, storage, or disposal &CWW <br />accepting tank andlor piping. <br />Facility Name:�CJ/C <br />Address: �5� / /QD 9 ✓) `Y /J <br />City:�%��/+/��!��: y514/ <br />--- EH M 046 (Revised 10/19/98) <br />Page 10 <br />JUL 0 7 1999 <br />ENVIRONMENTAL HEALTH <br />PERMIT / SERVICES <br />