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— SAN. �AQUIN COUKIT PUBLIC HEALTH SER ,CES <br /> ENVIRONMEMAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TAMC DISPOSMON TRACKING RECORD <br /> .N ............NYy Ny;ywv elwiliNll#w OtIOy RO.#1411;4w1..yw/hyla Mi Y4i#ia1<lt;;;#Haa.if ii M wiur.Yu+>s+ <br /> SECTION I .Public Health Services E.hvironmentai Health Division Tank Tracking Sheet shall accompany each tack afftaed u ur, <br /> its site identification number. The Tank Tracking Sheet is to be retuned to Public Health Setvices Environmental Htaltb Division <br /> �yithii1330 dam of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring chat <br /> :his form is completed and ree med. <br /> FACILITY NAME:_ _ T�11�� _._.___. .._.. <br /> FAcn.rTY ADDRESS: O <br /> _ ,t _— y,... ... <br /> 101000 O/cr) /4Jr Me — Uor Ivo. i <br /> TANK 1D#39 • ---TANK SIZE:i-c,, ,_ u , PREVIOUS TANK CONTENTS:__Q(�e 641--_00 tj­ <br /> ♦.yyY#!l4a..a.i...............;y#.yrt*th.TartM4#wwt!#lywtRt;.yl.#.t...rt#Mt....rt..at.<.w.•;rt.rt+rt...Y4... .... <br /> S'FCTION ? -To be filled out by tank remora! contractor. <br /> Tank Removal Co/n�tractor: : ez) C Q p �AvtfO (I 1-n (1i(A ( C <br /> Address: 9OA7 �j . 1150n ��`� City:_ STX ton Zip: <br /> _ ,O �Q Date Tank Removed: 01—IS-9t) <br /> .............s.#..Ira+y#!#.4h#.;+a.1.aa4h4>+.4...thlh4i#;wY;ty.ran.a.F.#M;.<.+en;.IY...........r..e. . <br /> SECTION 3 -To be filled out by contractor "decontatnibating tank"t <br /> ank Decon <br /> ta <br /> mi <br /> nation Contractor: i1J� nl q C�iLtp n tY1Qr� G 1 pn,C• <br /> Adarets:_� pG� 1, JSon WA `{ clty;_ 5TAeK7c0 zip:___1520_ .� <br /> Authorized representative of contractor cenifying through signature below that the tank has been decontaminated in an approved <br /> tannrr as requited by Cal EPA. <br /> Name:_.f.U . ��_Title: • ST Signature: Date�.`�-19-9' __.. <br /> n..>...Y4. <br /> ................... y.##y##.#4iii;tiy;#tt}yt#;;rtYYtl�wiyhlll.YMV11K {IV yi#1#4.;.;#x..ty.iYa Y#»+.e• <br /> SECTION 4 • To be signed and dated by an autboriztd representAtive of the trestnteht, storage, or disposal facility <br /> • acceptngtank and/or piping.. <br /> Facility Name:�E_�L_ coa <br /> a CE� <br /> Address:Y�0 . <br /> Zip: U_/_._... ._ .. <br /> Phone NO ( •. )� <br /> Dale Tank Receeiii%-ed: <br /> Name: Lf CGS O U Title: �1A2�r Signature: /-Date I . tri <br /> •wq....Y................#.+;i.Leyyia.M <.y44i...u.......................Yiy.Yii.............f.....H,_. <br /> P.H 23 046 (Revised 10/19/98) Page 10 <br />