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;AUG-29-2000 16:52 P.01 <br /> SAN SOAQUIN COUNTY PUBLIC WULTH SERVICES <br /> L%AIMON EENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .rrrrww••.rrprwra•Yw••.•M.WT....•.rr..........rrYrs ..wu.....err......r•rrr.Yr..•rrr•........... <br /> SECTION 1 - Public Health Services Eavooumesant Health Division Tara Tmcitaag Sheet shall accompany etch trek affixed wits <br /> in site idewificadoo number. The Tank Tmck=g Sheet is to be tenoned to Public Health.Services EavitoemeMal He" Division <br /> v.lthin 30 dans of acrepcance of the tank by the dispoW or rceyd* facility. The permit holder is responsible for amurin;that <br /> this form is completed and reouned. <br /> FACILITY NAME: `c k RA'CR f747_111,11 <br /> FACILITY ADDRESS: Y;2 <br /> TANK ID#39_��•J i3O TANK SIZE:02!cL�PREVIOUS TANK CONTENTS: (:�!e s F A:-� - <br /> rw.r•rw....•r-.a•rrur•........,...u.r w«..rw•ww..r...•.«...a..•.r..........r.............•.....r..r». <br /> SEMON 2 -To be filled out by tank removal contractor: <br /> Tank RcraovziCcnaactor: L- 4R fLnNt nom' _Qa rn C <br /> Address: Q9 E4- 41 Crty:�Z'p: <br /> Phone r: (afJQi ),2 3 1.u�O(A_ Date Tank Removed: <br /> w••radiMT.s........w..P•gw..MO sssM.....wrl.rrlv..rrOwt.r►PssMr rnnrrwrirrTr.........4T...... <br /> SECTION 3 -To be filled out by eon8actor"decornamir rWig tank": C J -&FWV tvQ^ nqq t <br /> Cc�uc�rxcn: GO _ <br /> Tarik Deconumination Cunu�[ta: <br /> 'YO?� V U O,� y .✓ 9 <br /> Address _ d �l11/�A . .: , 9 City: 57- t Zip: <br /> Phone <br /> Authorized r throe si attue below that the r decontactiaat d in an - ori <br /> epresentative of contractor certifying 3h <br /> mw=r as required by Cal EPA. <br /> Name:wl:•Z �.� Tide:[Zw�---� Slgsurnre <br /> t. <br /> r.wr....u•.......r.wa ............ <br /> rr r.•.rrr p r...r.ro•r•rrlr.ra..w rw..•'• <br /> SECTION 4-To he signed and dated by an authorized representative of the treatment. StofIV,or disposal facility <br /> acceptmg rank andlor piping. <br /> ret1 `� <br /> facility Name: il C - <br /> C'� f <br /> Address: l (llt � 1 u. City: '2 zip: <br /> — <br /> Pnone (J) r3-7 -`f 2(p e, - <br /> Date Tank Received: F–/ – <br /> Tidt ,jqr Sid a ute Date_ <br /> Name: ✓7 �-- -- u—MM.•r............ <br /> ................. <br /> o............................M..riTe.W <br /> .... . <br /> EH <br /> EH 23 046 (Revised 08113199) Pa"e 10 <br /> 100 { 7R/A CAU ATC:97f tit unttnnvtrttnn ov an At lenttnn t+ •nnv <br /> TOTAL P.01 <br />