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06/14/2004 16: 39 2094671118 AGE STOCKTON PAGE 04/06 <br /> 06/14/2004 16:14 66695. CAL-COAST PAGE 02 <br /> SAN JOAQUIN COUNTY PUBLIC MEALTH SERVICES <br /> r InNVMONMZN`FA1w HEALTH DMSIGY <br /> % UNDERGROUND STORAGE TANK DIVOSMON TRACTMiG RECORD <br /> i <br /> wrirf.r.rrYrr.r.ww..rr..Yr.M......qwy++rrrlw+HYru.rrwr..wrrYrprr•wnp..............rwr Y...... YYrwr <br /> SECTION I Public Health Services Environmental Health Division Tank Tracking Slhea stall accompany each Lank affixed with <br /> its site idemlfirnion number. The Tank Tracking Shea Is to be returned to Public Health Services Environmental Health Division <br /> �Ithin 30 days of acceptance of the tank by the disposal or recycling facility, The permit hcider b responsible for ensuring that <br /> thin form is completed and/returned. <br /> FACILITY NAME: (,./A r—P—U <br /> FACILITY ADDRESS: 3I7 7 E. F2L(►1Q/ll i 5MZsT�' (}1 <br /> Yw..r wwwf hTANKID/39- JS 3 TANK SIZE: ? PREVIOUS TANK CONTENTS:Affi & <br /> .......Yru............... ..worw..nr.. ........ <br /> SECTION a.To be filled out by Lank removal eontradar: <br /> Tank kemoval Contractor: QDMI-X'+D 6Wk- /I,,,A ,*- C <br /> Address: QQQ r7 /lJr <br /> 1,0l ! SE) City: 5Zip: <br /> Phone a: Date Tank Removed: Or <br /> wrr....uuw...rwr r.w ...w.w.ua.................w..Yw..w...wr..ww..re........•.♦...........w.wuq rr..arN. <br /> SEC'ITON 3•To be filled out:by contractor"decontaminating tank"; <br /> Tank Deccmtmination Comractor:__�Q_V/�JJGp`I� (�,�� ✓I( /I�MlG .-, <br /> Address: �7' 5 City: S70r, Zip: <br /> Phone Ot ( / ) 44y7.:.180 <br /> Authorized representative of contractor eenifying through signaw¢below that the tank has been decontareinsted n an approved <br /> manner as required by Cal EPA. �• <br /> NameTite: lgnature:� j�8ae1� <br /> rr........r..w•...rw.....ww.rw.�.......... <br /> 0...wrYw.r.rrlrw.....Yww.www nr....www..i..........up.r.+Musa <br /> SECTION 4.To be signed and dated by an authorized representative of the treatment,storage, or disposal fat lity <br /> accepting task andJoor�rr�pipin,gg/,,,- <br /> Facility Name: -Y" '!_P�t�j9t <br /> Address: l Zip: <br /> Phone r: l ) Gj��2e <br /> Due Tank Received: d(--/�-12 ',�, <br /> Name: y 1 //��� <br /> Tide: f�711��_^Signann: `-�' <br /> w...............r...♦...Law..00.o....... ............ ....................................... ........ <br /> EH 23 046 (Revised 10119199) page 10 <br />