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SAN)WAQUIN COUNTY PUBLIC HEALTH SERVES <br /> ENVIRONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *ww+wrwxwxrxrx+w+wrtwrtsxxaxwrtrxrxrwxx+*+xrr*+rras+xxrrx+xxwrsrrtwxx+xwr*r*rtxxwrrtrtrx««xxxrrrtxx**+rtrr*x+xxxx»*+ <br /> SECTION I - 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. /J <br /> FACILITY NAME: Shaw✓u' T rg-xi q W <br /> FACILITY ADDRESS: "{I1# N• &Oadpjzj S'ocrlon CK}- q.5ZT <br /> TANK ID #39 - `J,�5 D I TANK SIZE: 560 PREVIOUS TANK CONTENTS: 47,fr1inP. <br /> rrrr*r#*+*rtxrrr*rxrrx*rr***rrtrxrxxx*4rtrirr«r+rx*#firixrr*xr#rxrtrtxrrrr*«rxrxxrrrtr4+*rxxxr*r*rwxx***xxx««xxxr* <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: PAX &4- EXf QVAflrg Tre., <br /> Address: QLQ611 <br /> �''{11/� City: Riven..- Zip: ar7 u(o <br /> Phone#: Date Tank Removed: <br /> +ww+»*rrtrtxrx+rtrrrxwwwrtrwrrrrrrxrrrs**rtwxrrxxrtxrrxsrw+*wxwrr***xrxwr++rtrwxxxx*x***«wxxxxrx****rarrr+xxxr*rr+ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Paydl(+- —Y('611f1'&% 0 rl1f� �y <br /> Address: b n S1' Ciry: Rion Zip: q!5 5W <br /> Phone #: (jgq ) 99" 0L,341 <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 /> xrww*r**rtrrrrr*rrrxxrxsrwr*xwwwwxrrrxxrxrsrrwrrtwrrxxrrrrtrtrrrrxrxrrrrrx*rwxrrrrrxrrsxrrrtrr*r«rrt*rrxx+**xrrxr <br /> SECTION 4- To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting <br /> t tank and/or piping. �r"_ <br /> Facility Name: i a I eba51' I/�7'-cL. /� <br /> Address: 16qo I- v14 ?ff,aM Ciry: TuorcL Zip: ,,j-5sn <br /> Phone#: (� ) uu 0 - 4✓0 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> +www*r+rr*rrrt»rt+wxrrrwr»w+rrwrwrrrrrrrarrr+wr+rrrsw»wrxrtrtrxrwr+rxrrxrrrw►rrrw*+*«»r*rtrtwrxrrrrrrr+*rr«xxxr <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />