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12/18/98 FRI 09:33 FAX 5106096.104 RHL DESIGN GROUP RAL PETALUMA Boll <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACIONG RECORD <br />#WWWWW#WWWY###W#####WWW#WWWW#WWW##rt##Y#rtW#W###WYWWW#iY#WWYWYWWYWW###Y##W#q##WWfY#WYWWWWW#�olWakMY#WWWWW#WYYWW <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: AI (L p o RT SHELL <br />FACILITY ADDRESS: 1-51 <br />TANK ID #39 - 10q a3 TANK SIZE: S,('JGO PREVIOUS TANK <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: K - E Cur'HS Corn5TR.uc}ty✓-, <br />Address: I `TOC) OLD C.onglo RP City: NounAtmLy A✓ ip: q 132 O <br />Phone #: (9 I (o ) -116 - $ S S 8 Date Tank Removed: <br />YW##WWYW##W############W#W###########W###W###Y#########aF##############WW###############W#WW#WW###WYYWY##WW# <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: '6 xrreekyl ST Cirv:OCL A0 Zip: 114402,1 <br />Phone #: (S 1'D ) (033. 033 to <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Tide: Signature: Date <br />####W###rtW W##WWW#rtWrtrt#W#W#WW#WW#WWWW#rtrt#W#rtYWWYWWWWWWWW##rtrt###WWyYWYWW#WWW#W################iY############# <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: LCQ'%10%1 t 0V <br />Address: I63o ST city: Lomb, 590ck Zip: Ct oS13 <br />Phone #: <br />Date Tank Received: <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 10119/98) Page 10 <br />