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Jan- +-- - - - - <br /> SAN lOAQtjv cowry PLBLIC � "La S <br /> HE <br /> mgMONM VIAL AL <br /> ON <br /> UNDERGROI1Pta sToRAGE TANK DISPOSITION TRACENG RECORD <br /> •..r....................w.u./.a....our.lwrwww....u..I.l._`. ...r.Pa. tacbi tank affixed with <br /> ....f..rr.a.... 'zoom any <br /> SECTION I - Public Health Services Eaviroa>aental Health Division Tamrncd nk <br /> Publo is Health Serncz' 1rlvjXQ=cm'l Health Division <br /> or recycling fatilicy The permit holder :s responsible for easurint tbat <br /> ;u site . dumber. The Tack Tracking Shea is m be n <br /> : .i, 90 da of acceptance of he tank by the disposal <br /> chis forth is completed and returned- <br /> FACILITY NA,MF- Exxon #70136 <br /> F.SCIT.ITY .kDDRE5S:. 642 Pd If iC Avenue, St PpEViOLS TANK CONTENTS: <br /> YANK <br /> ID 939 - _ ,1211TANK SIZE:]�931� <br /> ..............................................a.......... <br /> .I.w.f.r....YY...../......a....f..I.a.f./....Y... <br /> SECTION 2 - To be filled out by tank rcmoval contractor: <br /> Tank Removal contractor: Pile COflstr Z. <br /> —^ <br /> address: <br /> P.O. Box 2936138 City �`— <br /> Phone :: <br /> 916 )--Q8 ' Date Tank Removed <br /> .. <br /> ... ......... .............................................. <br /> .............t..................... <br /> .a............... ........ <br /> •• <br /> SECTION 3 •To be ftLed out by contractor "decontaminanng tank <br /> Tank Derpmamination Contractor: Pile <br /> City:—sauamat$--- <br /> Address: P <br /> PSove N: ( 916 ) oatatninated n an approved <br /> Authorized representative of contractor Certifying ==ugh si Vature below hat h <br /> martur as required by Cal EPA. ,4- <br /> �,�,,� �i �Q Ti+le: Sigtarure: <br /> Date <br /> Naate <br /> ♦w.u.rw.u..........n..tau......uw.vur...w....w.......f.w ..u....ru.l.r.a.....a...u......r.r. <br /> SECTION a -To be signed and dated by an authorized represeatative of am treatment• storage, or disposal <br /> facility <br /> accepting tank andfor piping. <br /> Facility Name: Zip: �f <br /> City:�-�-.— <br /> Addtess: <br /> P1one :Y: <br /> Date Tank Received: Date_��-� <br /> Name:`._ <br /> Title: Signature: <br /> ..r...fer.....o.......... <br /> ....................................a...............ra............ u....f..u. <br /> I <br /> EH 23 046 (Revised 10/79/98) <br /> Page 10 <br /> .we'd Ez20-299-0E5-393M-'.`1N7-071.147M bV-CT ac CT 'wr <br />