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1t`2.'1991 09: 50 FRIM SE MOPESTO CG. DIV. TO 146 8 P.03 <br /> SAN jokpk COuiv'lY <br /> j0GI KHMNA MZJ L?.H . . <br /> P,0.B=2009.E(1601 I=Fia�etttlo ATMOO)0 Uod=06 CWWXUia"201 •� � ��,:• <br /> WMERGROUND-TANK DI.SPOSYTIONTRACKM RECORD <br /> ##rri#!#rr#rarrssslrlrlrraaaa##i#i#iii•#illiii#;�'iiiiFiRi'#i#ii#iiiisrrsi*i#iiiiiiiiRiiiiriiiiiiRliisisi##rr• <br /> SECTION 1-Public Health Services Z'rackitig:Sh et will act ouipany t-1 . task affixed with its site identification number. Inc <br /> Tratking Sheet is to be returned to Public Health Services MJiMn 304ays ofargptance of the tank by the disposal or recycling <br /> facility. The permit holder is responsible for ensuring that'this;form is +completed and returre, <br /> FACILITY NAMM P 4-ti ; <br /> FACA..I~lY ADDRESS: , G . <br /> TA.NX M #39- I 6r '� 4, 'Tafifilc De=iptk=. <br /> iis#iii##i##ii#lir#i#i##i##Rei•ii*###i##ii#*w*#�*#ii.#.#i#ri:#�*iii;#iRRRRfi,i##iRiii,*i.i#illi#iiiiiRR##i#iii#ii <br /> SECTION 2•To be out by tapiC r=ov., contractor:. <br /> Taak Removal Contractor: <br /> Address: i¢� gty; 17�p Zip: S3S/ <br /> Phone #: ��_-57 Date Tank- timoved • <br /> 4ii#i#ii#r#fir###rri##i#iii#iss#iiiiRiiRlli#stiiii.si##�#isiiii##'iR#is♦sF,Riiiii####ii#t###ii#fir#i#!!liiiri#rr <br /> SECTION 3 -to be filled out by aattMotor.'downtam1bating`.talc";.: :',' ,,:. .. .: <br /> Tank I ntaauaation Contractor: <br /> Address: 3• Cty; d4so 7-1p1 <br /> phone#: �,,.) - 96:3 , , • . <br /> . - <br /> Authoe=d represeatative of contractor ceriiEed by signing below.that•the tanlr has been decontaminated is an approved <br /> manner as rewired by the State Department.at Health.Services„: <br /> Signature: 'Titleit pr <br /> • 4 <br /> •moi_---- <br /> !s*r#s#r#aiiiisiiRs#ssr#ani#asa##iiisrsris.ss�sfis#ssii'#s*8xa*s**##i!!!'srsrsssiiisiiRRr#iR#ii#iriRr#sss#asss <br /> SECTION 4-To be signed and dated t�an..authorlaed.represen"ve of the:treatm=4 storage,or.,disposal facility <br /> accepting tank and/or.pipiuv- <br /> Facility Name: CAL. r.QAS_3'_ <br /> Address: A4 S._ _SEC NF,R _._.._ :.. qtr,-T11 Rlr KL Zip: 9 5 3 8 Q <br /> Thgfite #: ( 209-J)-- 568-9378 - <br /> —1r I^ Ili. —■1„�,I�i' n14i.1���� <br /> Date Tank Received: <br /> Signature: <br /> ; ##rr#i1i##ii#ilii#rssast#s#sitsi#siiririiiiiiiiiiRiiiitRisi+lR�i#ssiiii#'#si##*iiiiiisw#i*ii#i#iiisirrRrlili• <br /> P886'1D. <br /> E8 23 049 (ROY 2/8/91) wp <br /> A DMMM-01 Sia}ersquin.Casser M..ikh Cant ftWIC s ' <br />