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J6.. <br /> SAN JOAQUIN COLIM PU81LIC 1�2- TH SERVIt ..' <br /> L.jMON�PTrAL HEALTH DIyISION c CORD <br /> UNDERGROUND SmRAGE TANK DISPOSITION TR.►C1QN <br /> ..a..r...........r.u..............•••ra••••••�•r.rrlCel Shill aCCOmpafiy each tank affixcd wi[h <br /> .a...a.......r- k Public Heahh Strvsces OMP&c mems! Health Division <br /> SECTION l Public Health Services F�rtonmenul FlWtlt Dc returned <br /> et rTrak Tracking <br /> or recycl ng fac'1iry. The permit holder is fesponsibie for emuriag that <br /> :u ;;'e ideatifiution nua'ber. The TaNc Trackiag Sheet is w x re <br /> within 3 a of acceptance of she =k by die disposal <br /> this form is compieted add renifned- <br /> -FACILITY NAME: axaN #70136 <br /> CA <br /> F.•,,CILITY .ADDRESS: f i Q <br /> 171)DL_T.-JNK SUE: ,n pREv10tJS TANK CONTENTS: <br /> TgNK ID 3'39 ...w..wa...ar.o..o. <br /> ..........v....r......a........................*........r............................ <br /> SECTION ?.To be filled Out by tank remoysl contractor: <br /> TarkRtmOval Cotnfscsor: Pile Gmstar-tion CaammtO _Zip'.��i�Q <br /> Ciry: rr — <br /> Address:P� X <br /> Date Tan �� p� fpcormlrlPf{ <br /> k <br /> ..............................&.........................................................................in. <br /> ing�. <br /> SECTION 3 • To be Gilled out by contrador 'Pco 2mill fLlCan ": <br /> i <br /> --- <br /> 7=k Decorimw 60n Contractor: <br /> Ciry: —Z'p:�-- <br /> +tddress: <br /> ?Sone x: ( C116_> <br /> chrou;h sianauire below that pa{Dpc decootamiaated is an approved <br /> ithorized repasenutive of contrac'nr ctrufying /I <br /> manner as required by Cal EPA. <br /> SignatureecocrA. <br /> Date t�l��_ <br /> Na=: ,•,�,,, of to _ _Title: (ttnPr - <br /> •r....ru................................a r..............p..pb. ............p.r...r... <br /> tolle ar disposal facility <br /> SECTION 3 •To be signed and dated by in authorized np'esentadve of theg <br /> accep=9 tank and/or P'P'09' <br /> Ficilir Name: <br /> Address: <br /> Pboua 4: <br /> Due Tank Rece'ved: <br /> Name: <br /> Title: Si'�awre: <br /> .rw...................r............................ <br /> ....m....... <br /> runs.p............ <br /> .......... <br /> ......... <br /> EH 23 046 (Revised 10/19/98) Pare 10 <br /> biZ'd E120-299-065-x'12-t-'MI7-n-a��ic�M c�•r. rr -. •...• <br />