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Jug• <br /> SAN JOAQUIN COUNTY PUBLIC "'LTH SERASS <br /> ENVIRONbCZNTAL HEALTH DIVISION <br /> U"ERGROUND STORAGE TANK DLSPOSMON TRACXXNG RECORD <br /> u r.ror.r...upq.......q r..r..u.M....r........................0.........1.rrH.. <br /> ..................... $Acer shill accpmpaaY cacti tank affixed with <br /> to Public Health Strvices Ehvirottmea a[ Healdt Division <br /> SECTION 1 - Pubnc Health Services k Tracking <br /> ral Health Division TaaY . The permit holder is responsible for twuriag that <br /> ;u ;ire identification cumber. The Tank Tracklag Sh�is amerex 1C�"��iry. <br /> w'th' vs of aceeputte of the tack by the disposal 4 <br /> ;his form is completed aad retroed. <br /> FACILITY NA-MF! SOC <br /> FACILITY ADDRESS: 6425 PaCific A Rai <br /> p�VIOUS TANK COtrSEV� . +n - ` <br /> TANK ID a39 21�--T'aNK SIZE:�QrL— .. <br /> ..rr..r.r.....w........urv..w..r.r...................ur..............r.u.r.....wr...rar..r....r. <br /> SECTION 2 . To be Ned out by tank[esaorak eontr+dor: <br /> Pile Cfx)structim <br /> Tuk Removal Contractor: Zip: <br /> PA 8Dx 29YO88 C'ry. ��-- <br /> AddIL55:��— . <br /> CoQ rneti Date Taal;Removed: r0 <br /> Phone 9: ( g1Fi ) � ............................ <br /> ...............r............. <br /> SECTION 3 • To be fled out by con[[aetor "deeon[atnimting tank <br /> Tzak Decantauiaation Contractor: Pile Can <br /> City; -- <br /> zip: <br /> Address: P.O.•�• BOX 29 <br /> phone e below that the w1k has t oataminated in as aPProved <br /> Authorized representacive of contractor certifying tlttoua�t sigcuurj <br /> manner as required by Cal FPA- <br /> Name; <br /> JdTt Pile— signature — <br /> Tide: <br /> NamC: ro.....u....urs <br /> •........uu........v..............0....u.a.M..N...r .. ................. <br /> SEGITON 3- To be sirped and da[ed by zn authorized represet[ta[Ive of the anent. storage, or disposal <br /> facility <br /> accepting tack andlor piping. <br /> Facility Name: <br /> Ciry:�.�.f-• <br /> Address: <br /> Phone C <br /> Date Tank Received: <br /> Title: Sigpamm; <br /> ..............rr........•.......ur.....o.....................ro..r... <br /> EH 23 046 (Revtscd l0r 19198) Page 10 <br /> . ,Dif.'d... ._... .-.. . 6.'..20-299-RFS-Tl'T1-'MIT-n-iln C7nt r�-•-r Ce .. •ti. <br />