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I2!18/98 FRI 49:33 F':� 51060 04 <br /> RKL DESIG GRO(IP *� RRL Y1I:NLUZA 4 oal <br /> SAN SOAQUM COUNTY MUM T&4LTH SERVICES <br /> ENVIRON MTAL BEALTff DIVISFON <br /> LIERGRQ S'i'ORriGE TAPS D QN TRAC93NG RECORD <br /> t #�* Fa+a�a�+�r,ra ,ntagnkNiywM <br /> .. w1ia�Irf�rc+Mels*�#M�ieluMwrybas rMeMe . <br /> SECFION 1 - Public Health Services F��Heaiztz Division T Trackmg Street shall accompany each tank affixed with ; <br /> its site idea &%Aon=tuber. Tae Tank Tr=king Sb=t is to be remrae grit Health Services Envixoamentat far ez�r exissstr�h Division i <br /> within 30 ds�of acrzpu=e of rhe tank by the� or�g • The �k is ��'�e ug that <br /> this form is completed and r rned. <br /> FACUJTY NAME: 4 R orT 51�e l <br /> FACII.ITY-ADDRESS: <br /> TANK ED#39 - 1)49 _0 /. TANK ME: t�,DSD PRE US TANK C©NT'ENTS: 2 ASai Ale <br /> SECTIO 3- To be fMod out by it wA removal eoWx2c ir: <br /> Tank Removal Conttwwr: 1'�• '� ��lo,r'� <br /> Address: oo o� <br /> con -10 R0 City: ar ._ X32 0 <br /> Phone #: ( #o ) [b- 8 5 S S Dart Tactic Removed: <br /> SEC'I"ION 3 - To be filled out by cout rwar"decontamW2tiu9 tnk <br /> Tank Deconmminwicz Conu=or- C r a Sb ail er v <br /> k14no <br /> Address, 16 q <br /> 3a It S-r. clty: O zip: <br /> Pbow if: �_ v (0 3 3- n 33 t <br /> At dmfizad representative of canaactar cenifying dvough sig�tnrc be <br /> that the tank has been decatzsautinated in as aglrroveti <br /> tnartner as required by Cal IPA. <br /> _Date y� <br /> SE MON 4 - To be signed and dated by an authorized rWesrt of the ueatmc= storage,or disposal facThry <br /> ac=ptiang tank=&or piping. <br /> Facility Name: �f <br /> Address: J� city: Zip: <br /> Date TankReceived: � <br /> Name: 1 Dace <br /> �. IFFC <br /> ~-" Epi 23 046 (Revised 10119/M ftge 10 <br /> J U L 0 7 1999 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT / SERVICES <br />