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SAN,-.vAQUIN COUNTY PUBLIC HEALTH SEI.. CES <br /> ENMONNMNTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> tlrNf rrrgrrrray►Y►Hr►rY►rrr#►\rrriaq\rrN«frr«wrap r#rp►►ra«rfr rgrtr airr#raf ar##r#+«f«r#rest r+#►##re,+ <br /> SECTION 1 - Public Health Services Environmental Health Division Tads Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be ret u led to Public Health Services Environmental Health Division <br /> within 30 lova 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: tc: _ Tstor%ot Rvx^rt <br /> FACILITY ADDRESS: rot*c .te,k C,tBt,4, mje Read - - - - -- <br /> TANK ID N39 - rArt510: TANK SIZE: y eco�. t PREVIOUS TANK CONTENTS: fT a*"etc �rC✓J <br /> aargrp►•\rt\r re,rr►+r►rr.p rrrrarrr►\r►a►►rrr+Mp►arirarr\►r►iar►araYi\rprrrtr\sarrrrrrrp+rrf iaprrr r a <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: P 7, [.,,, 4e,. ,4lo� <br /> Address: A.o. 3.w »at.x City: beero,.e../v Zip: 9583fr <br /> Phone M: ( 9/& ) 491- .676.q Date Tank Removed: <br /> +Yr►r+rYN#Yra#«ar\\r►Vrw►fra+arrarar►«Yr«#r«aspriMaia#traits#arsrYHrit#aiarrt►«#«rrrq►Nr«rrM«rrrrrr«i <br /> SECTION 3 -To be filled out by contractor"decontaminating tank": <br /> Tad; Decontamination Contractor: P:Ic Le sa,.+cL/e <br /> Addmss: P.aBox 243425 City: Zip: 951�a <br /> Phone/: ( ie,. ) 48Y-S4!S� <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> tanner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> Y►YpYr#a#rrra#iYrlfM#►#«iV#r#Y#rHr\IVrrM\#r#q«rIM#Vr#«rVrirtYVVt«r#«Mr#r#►rrraf##aai«r►«r#rrr►«#«##tar <br /> SECTION 4- To be signed and dated by an authorized representative of the treatment, storage. or disposal facility <br /> accepting Lank and/or piping. <br /> Facility Name: E.r,leaeA <br /> Address: ass Pore, Bind City: Zip: 9vg07 <br /> Phone N: ( Ito ) ass- 144 3 <br /> Doe Tank Received: <br /> Name: Title: Signature: Date <br /> MYr\trrYr►re,\Mai\VMa\i4#r#i#fartrr\re,«i\raH\\##1►qr\rrrr#riRrr►rrY«r+it«ri«fa#i##«rw«rrra#ar.arY«Y\«r# <br /> EH 23 046 (Revised 10/19/99) page 10 <br />