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y <br /> SAN)' AQIIIN COIMI-Y runt.IC DEALT It SERVICES <br /> ENVIRONMENTAL IIF,ALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION 111ACKING RECORD <br /> ««M♦••Na♦f#♦•♦4♦a•a M•N#aa#M•+aaM###lMaM#4!♦#•N•aa4+##aa!##IHffffrr4Nrlrfrfrrrrrr♦♦♦r♦r♦Nf♦rfff♦ <br /> 51EC TION I - Public Ilealah Services Fovhonmrntal Ilcallh Division Tank Tracking Sheet shall accompany each lank affixed <br /> will, Its site Identification number. the Tank "1'racking Sbeet is to be returned to Public Health Services Environmental Health <br /> Itivisioo eilhin_30_days of acceptance of the tank by the disposal or recycling facility. The permit holder Is responsible for <br /> rosining aunt this form is completed and returned. <br /> 17ACIL.Il'Y NAME: Rpilly's Car Wash G,I',A. 11 CAC 001481312 <br /> rACII,l I Y AhDRF.SS: 100 E. Lodi Ave. , Lodi, CA 95240 <br /> TANK ID 139 - _ TANK SIZE: 000 PREVIOUS TANK CONTENTS: Unleaded Gasol inp <br /> ,++«•N•f r K•«H+++f a H#la Na•H«raro•M!M#•a•#r#a!♦M!•!H#a♦NN!#r►#++#4f4#Nflfl HlMNQr►f Mrrrf♦orf♦ <br /> 3F(:"IION I - To be filled out by lank removal contractor: <br /> lank Removal Contractor: Jim TIlol'pe 011 Inc. <br /> Add,ess:_351 N. Beckmalr lid./P.0. Dux 357 City: Lodi, CA Zip: 95241-0357 <br /> Phone 1: ( PO9_) J6B-61L5 Date Tank Removed: <br /> ♦ff•ff«««•af«••♦••+«♦ffr«s4#f##r«+#+arf•l+ta♦a#a+f•rf•#••ff♦!•#•♦+!!#af#a4frlfffrrfrrfl4f♦rrr♦♦r♦roof♦rrrrr <br /> SF(:,I*loN 3 - To be filled out by contractor "decontaminating lank": <br /> Lank Decontamination Contractor: Jiro 'Thorpe 011, 111C. <br /> Address: 351 N. Beckman lid./P.0. Box 351 City: Lodi, CA Zip;95241-0357 <br /> Phone 1: ( 209 ) 368-6175 <br /> Aoduoiud aepresroladve of cmttrsdor certifying Through signature below That the tank has been decontaminated In an approved <br /> rummer as required by Cal EPA. <br /> Nmue: title: Signature: Date <br /> . .+♦ . ... 44l+rr tar • •« !a4•ar4 + +! #aa+4f a!#•a#ra:ffar!lafa! # l4arrf N ♦ • rr♦H♦ *♦rr r♦♦♦rrr <br /> lark is free of af( �ludyes an11I dro5arhon vajtors soon cPefi�ver o 'c��in�t gr tees. <br /> SF,C" lON 4 - t o he signed stiff dated by an sod mr re represenis Ire of the treatment, sto age, or epos aril ty <br /> accepting lank and/or piping. <br /> Facility Name: SchniLzet- Steel I'rcxlucts <br /> Rancho Cordova, CA <br /> Address: City: Zip: 95742 <br /> Phone 1: ( 916 ) 995-413 10 <br /> Date Tank Received: <br /> Plaine•._ —Title: Signature: Date <br /> +!•a•«♦#f+a#4aHa•4!♦4♦•4alaar!!♦aa•#!a#a!!•aa#!+4la!!#•#l4ar++#!H#H##4#ffa#aura+!!#a•4a#4#ant+ra4ala+4 '. <br /> FH 23 oar, (Revised 9/11/96) page 10 <br /> i <br />