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12/18/98 FRI 09:33 FAX 51060963n4 RAL DESIGN GROUP RHL PETALUMA 2011 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />kixiiiiiiii#w#i#####»i»*#»»x#x»#k#iii*###rt#i*ixwiwrt#i##rtiii#wwii##########»w#iii#+kii#iwii####iixiw#iW##wxww <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: f,1R2orT She II <br />FACILITY ADDRESS: I <br />TANK ID #39 - /Qt(!cj —01 TANK SIZE:— 10, DO'0 PREVIOUS TANK CONTENTS: GASOL, �"" <br />###ixiiix##wwwww######w#####i###ix»iiiik##xxiix#####rtiwi#iisiikw####w#fiii#rtiixwiwx#fi#»#xx#x#x*ixxxi#wwxxx*x <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: K•E CkAV-kkS CDnSTRuL}tu✓1 <br />Address: I `TOO OLID Gon4ej o RP City: K76u Q✓ ip: q132 b <br />Phone #: (91(o ) —jI Io 8 S S 8 Dace Tank Removed: <br />#wirtwfirt#*fififiww*###w**rtrtrtww#*#k#w#rti##w*wfifiww#w#####rtii#irt*w###»*#wfi*i*wiwfi#ww*wwii#w#*ww»rtwwiiwi*www*wwwww* <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />sp Cr'osbti j Duerr.' <br />Address: `a��JD NyNeklq ST. City: OCL klwnc Zip: 0/4toZl <br />Phone #: (rJ I'0) 10 1p <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />nuumer as required by Cal EPA. <br />Name: Title: Signature: Date <br />www»w*rt*wrt#w###rt#w#wrt*wwwfi#w#»wrt»fi»ifi»##»#wrtw#wwrtrti***wwww**fi#»iwwiiw##»iwwwwwww»x#»w#w#x»fiwi*»ixii#w#*wiw# <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: <br />Cr'oe*�j <br />OV eCTlOr\ <br />� <br />Address: k6'2jo <br />W• <br />04+% S7 <br />I <br />City: LON6 geocL, Zip: 9 bTi13 <br />Phone #: ( S(.'L) t{32— S vyS <br />Date Tank Received: <br />Name: Tide- Signature: Date <br />EH 23 046 (Revised 10/19/98) Page 10 <br />