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12!18!98 PRI 09:33 FAI 51.0609VO4 RHL DE516 WKUUr ,-,Y Mai- <br /> f <br /> SAN joAQUN COUNW pUBUC TH SMIC.'E5 <br /> E WMOMWENTAL MAL IIkt M%Cff <br /> UNDERGROUND STORAGE TANS MPOSMON TRACKING RECORD <br /> ------•�'....i.wi.,.,p,d,,nkae� atr.+wr,.�r,r�r**www* arc , <br /> SECTION I-Pabiic Heidi Services EuvUM==W HgaLt Division Tanic Tracking Steer SbAR— 111 any each tack affixed wdh <br /> tm site ic#e=fication rmmbe'. The Tank Tr=kng Sheer is w be==edto public Heahh Ss nn=Env==e=21 Hea1[5 Division <br /> '1 bolder is yIe for ens that <br /> within 3E1 dans of arcepraace of the tank by the disposal or recycling r�panss wring <br /> this form is completed and rrnu=d. <br /> FACaXN NAME, tzt�or�t S1�e I <br /> F ACIIITY-ADDRESS: 1 Gtr _ a <br /> TANK M#39 - O i q ' y TANK SIZE: $) .7'D PRE OUS TANK CONTENTS: GA-.01,1N <br /> i <br /> SECTION 2- To be filled out by tat k removal cow= � <br /> Gt�� 5 i�l cs,n <br /> Tank Removal Contractor: VIIEi <br /> Aaaress: ©n <br /> oUD COnS O P-12 City, Nev,06uWu ar ip: q 132 ti <br /> Date Tank Rmcvcd: <br /> i <br /> SECI`ION 3 -To be filled out by contractor"decootaainWing tank": <br /> Tank Decontamination Contractor. Crsb �11er�o <br /> Ll� <br /> Address: $ © 2. t '�: City: Qa V.t4A0 Zip: °! ZI <br /> Phone#: t �3 t� } �a''�3• {�33�o <br /> Authorized representative of contxactor certifying dire a&A bek w that the tank has been decontamimted in an approved <br /> manner as required by Cal EPA. <br /> Name-,/,.t��/� _- Tisbe /s�G�`1� caaaQe: Dace L8 <br /> *��*�rw.x.w � �www�+swrwrw�a ,�+w+ w�..a•wr,��.«,. wr�x �*� <br /> 3ECTTON 4-To be signed and dated by art authorized reprexntativof she trear=t, storage,or disposal facility <br /> accepting rank and/or piping. <br /> Facility-Mme:��� <br /> Address: �l/D City: �,C�zip: <br /> Fhune 1: <br /> Dale Tank eceivcd: <br /> LIZ- <br /> Nam Nide: S' wre: I Date f <br /> r-U <br /> EH 23 046 (Revised 10119th Page Ifl <br /> J U L 0 7 5999 <br /> ENVIRONMENTAL HEALTH . <br /> PERMIT 1 SERVICES <br />