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SAN,1�,,WQUIN COUNTY PUBLIC HEALTH SERN4,00 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ii+i#iiii+#+ii+rt#f++#+#iiia+i#i»i+#rt###ii##rtk#f++i#»ii#irtri#+rt#rkrti#rtiif##i+#ii#+iFrtrt!#ifiiiiirtif#+++++rtirr <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 rettgned. i/� <br /> /LAR l� / l <br /> FACILITY NAME: \s t`'�la '� r. v' t �M FT <br /> FACILITY ADDRESS: 7/.S lqv. "UNtT262p r—�A <br /> TANK ID #39 - TANK SIZE: 3.5� G4LL-,-�PREVIOUS TANK CONTHNTS:QAS-Tf-- O t-t— <br /> is#rti+rti#i+irtrtrr##i#s##si+i+i#sirii++risrsas#irsrtrt#iii+s+##sii+##iiisrtrii##rt+##is+#iii.+riris+#ii+irfi#r.rt.# <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:IrvcS* c- �utcc -&yA Te,J <br /> Address: 950 21 /"o. L-t^316 3 s-r_ Cityg--T-v � Zip: g/k-zerc <br /> Phone #: (2�)4K�ef- Date Tank Removed: <br /> Flii++rt#1iii#iaa:#i##+rt+r»!#iiiirt#iirtrtrtrrrp#+#i#iifrt##r+ri4#iris+lr#ii#!!###»###kirwf#i#iii+##ri#rtri+###rt!r <br /> SECTION 3 - To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contracror� rl� .5r4.rr11t3 -- 6. c <br /> Address: 'Fd oSsc- Ciry ��toJ Zip:9SZo� <br /> Phone #: (;20q ) e16 of 8 3 3 3 <br /> Authorized representative of contractor certifying through signature below that the t as been decomatnmated in an approved <br /> [Wanner as required by Cal EPA. n <br /> Name: MIA, Title: T/1gF� 1/u,�Signa Date���6� <br /> i+if##i+i+i4rtfi»i#»»fi#i+i#irt»iiiiirt»rt#ifi##rifi#rtfriiiirtrtr+i+rt#fiiii#;ii»i»#irt+i»#iii»»#i»»rri»f#i+ifs#»irt <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: <br /> Address: Z57:5- City: Zip: <br /> Phone#: (S 6 ) ;?- <br /> Date <br /> Date Tank Received: <br /> Name: Title: Signature: Daze <br /> #ifiii+i###ii+fr#ii++i+si#iriiiiisi#ii+ir#ii+s#f+siiiri#irti++##rfii+sr#fiifis+ss##iiiirr#isi+fi+irrisrt#fi <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />