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12!18/98 FRI 09:33 FAX 5106096304 Rill. DESIGN GROUP RHL FEPALUYA toil <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENvIRoNmENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANS D5709MON TRACKING RECORD <br />rwr+sr..r..+�r+rr.r»rr+.++.r.asr rdsst++rrrwrmn.rs+.r+Iwr+rt+F+artr.rrrr.r+r.w,w....tri...rw.r <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sbeet shall accompany each rank affixed with <br />its site identification number. The Tank Tracking Sheet is w be returned to Public Health Services Euvixoomenad Health Division <br />within 30 dans of acceptance of the tank by the disposal or ttxyelmg facility. The permiat holder is responsible for ensuring that <br />this form is completed and returned. <br />FAC -M NAME: !'fq_?W7 5Ine11 <br />FACn= ADDRESS: 1,511 F;_� . o de k ee iA)dt 4 <br />TANK IDp39 - 1 Uqq 0-j) TANK SIZE: SJ DO _PREVIOUS TANK CONTENTS: GASOLINF <br />irrrtYiM+`rtrnrtrtMf+RY+YarYfv"wkFM/MrtY4IMtFiMrYY4+YMiMAiit►+FY+�itY+Ri W MsW riuYr�Y�rtirt <br />SECTION 2 - To be filled out by tank removal contractor:: <br />Tank Removal Contractor. k- E CkAr Arts <br />Address: 1400) oLD COne; o RQ city: NoAvwyh ar ip: Q 132 0 <br />phone M: (9 ((o ) ri t b $SSS Date Tank Removed: <br />•aMrw+ira�rsrrorswr�+lr�k+�✓rrsrrurrk�+r�k4s.FiYr++4wrrt VrrtM+IWirRFrtsssRsaV�wrtw+rrrrtaarrrr�Yr�Yrs�Fw+rt�wrrtMiw+s►+srrr++f�r.�.M1rt <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor. C <br />Address: `13430 4irnelta S -r City: Oaktano zip: 174(0 ! <br />Phone tt: ( S m ) (0,6 -6 - 0,3-6 (o <br />Authorized representative of contractor certifying through sigtaene below that the tank has been decontaminated in an approved <br />manger as required by Cat EPA. . ll <br />Natner✓'Iec4gw-"-Oe_ <br />Date LB <br />SECTION 7 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank anndloor, piping. <br />Facility Name-- <br />Address: <br />ame:Address: Xe_ zip: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />JUL 0 71999 <br />ENVIRONMENTAL HEALTH <br />PERMIT / SERVICES <br />