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SAN JOAQUIN COUNTY_ <br /> ENVIRONMENTAL HEALTH DEPARTMENT . <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKDQG RECORD <br /> •«was•.•••pw••rsra•rws•s usaaaa sprpia•s•sistpwurars apappasii•ssiarrY+Np iwirirrr+wriii <br /> SECTION I-S3C F.avironmental Health DepatrwWS Tank Traelwtg Sheet shall accompany each tank tff=d with its site <br /> identification cumber. The Tack Tracking Shaer is to be returned to the Haviroinientel Health.DWwwrent wits iu30 days of <br /> acceptance of the tack by the disposal or mcyclin facility. The permit fielder is respov abk for enticing that this Bala completed <br /> Md cct(uned. <br /> FACILIT mw: ��/r�[Jf 470��'TaN <br /> FACHM ADDRESS: (�D,�NP R �/y '� O/ rl Do xe Q 8 LO <br /> TANK ID#39- OS i r7 10- TANK SUE; /, S Q �PREVIOUS TANTS CONTENTS- 41641 'NO 4+ Al <br /> •;N•a•as.s.♦«a•rpaaiipissis;iiiFiipirarii.;;p►iprwYpp+•rrrrrrMaiiiiiuiirariirapssssss <br /> SECTION 3-To be filled out by tank removal contractor: <br /> TackRrnoval Contractor 6 e0 " r G <br /> Address- Q • h�a C S b c 1) City $xrw v (o Zip: <br /> '4phoae N. Date Tank Remomm : Z I — C)1 <br /> s sssr rarrisr«►uaaaasrsrsrsasraurar;rrps•s..•pssrsai/aN►rwipaaairprra;rarrrs«r;ssw. <br /> SECTION 3-To be filled out by contraetor"decontaminating tank"• <br /> Teak Decontammanon/Connectoj- CO�a4V <br /> Address: 2{•<- Pal/ AI City0.Z4:-S/.PO/ <br /> Aiabmiud tepresenative of cofactor ratifying throtyih sage to bclaw that the took baa been decomaminated in ac approved <br /> mamer as required by Cal EPA. <br /> Name:Z"dc W ' o _Titic.,skAL iSiluatute: -t- '0 6� <br /> •sas+.sparaiiiN•r•iNraar•;;•rrf;i••T;;rrrrr•a;•ai•raipiawifi N;♦/Y►rrssassssa;isii;•ssssisi4Fii + <br /> SECTION 4-To be signed and dated by in authorized rrapresentatNe of the tteattumt storage,or disposal f cility <br /> accepting tank andlor piping. <br /> Facility Name: /�rslciSTr,PS <br /> Q l - — - <br /> Address: a ei� Parr �l city ItCGm _zip= EM) <br /> Phone Ir <br /> Dais Tankk tceived: <br /> Namur 10'x. S`4{ iI OX Ttit1e: P� ,fi✓��ipasta[ . DateJG' <br /> •a;rrrY.aaaarrar•••r Nrs•aira;rwrwrsus•+.priipilapy araMMaYNpaa•rwrrraarriss+s <br /> EH 13 046 (Reviscd 10/16!03) Page 10 <br />