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SAN)esAQUIN COUNTY PUBLIC HEALTH SERF ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> kwk+###lir#WWrtrtrtk#rt4##rt#»r+rtirtrw+w+rt#####krtrtrtrrt++i##s######+##4+rt+#rtrt###*##i##rW####WWW###W#krtrtrti#+++rtrt#++rt <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: :5,, U nA (e�C','t N <br /> FACILITY ADDRESS: 2 OUj EST FR TMA nt- Slf ted <br /> /croon op,#OA <br /> TANK ID #39 - TANK SIZE: /p,ac. rnG,pr.n PREVIOUS TANK CONTENTS: t1oho ") 6,9Sn� <br /> ++++##rt+i#+###+#i+rtrtw####rt4+###wsrrtrt#+#rtW###Wrrrtrt#+rtrt#rt##kkW#r#rrtrt#rt+#+#rt##w###W##Wr#WrtkW4rt#rt#rrtrtrtrtrtr#rtrr#W <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: A d V&V(Qh Ce r, C nv iro'M PA4A I _JIK <br /> Address: 7Q0.5 NPATN WjSt�n WA `( City: S70LKirin �y Zip: _/5 750 <br /> Phone#: (204 ) b ] - 0 atk Date Tank Removed: <br /> #rrt+#Wrtrtrrtrt##W#+Wrt###s»rrtrt##rrrtr++#rt++rt+irt#44#»##»#rttirt#rt4rt####»rrt+rttrt+4#wrtrtkrtrtw4#+###k###rtrt+rtrkrkk###»#»#k <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: A a V n N(P1D l9 P c�nv o n m F n�, _T <br /> Address: y005 AA 47,q hh'Wrn Wo City: SjoC Ton Zip: 95758 <br /> Phone#: (2;s t ) Y4 7--100 ro <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: Title: Signature: Date <br /> rtrtwwrtrt##krtkww##»#r+rt+wWrtrtrt+##Wrrtrt+#WwWrtrt######kwsrtrs##W##Wswrwskr4+*###rt*Wksrs+rt■kr#rtwwwrtrtrt+rt+#+++#+##+++rt+ <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: W ES► Gj vOf N <br /> S T CC 1 <br /> ( <br /> n� <br /> Address: it Q &4. 23697 City: v Cr K Zip: 96sel <br /> Phone#: (2-0 ) fn n 0 — 9-37T <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ##rtr*kWWkrs++rt##rt»rtrt#»rtrrt##rrt+s#rrss#rtwssrtrt*rtrtrtrtrt#rtskwrrrtrt#rt##krt#rt#++###s#s#wWWk#»W+WksrWwrrtw+r#rtwr++#+++ <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />