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SAN JOAQUIN COUNTY PUDLIC 111EAIM118911VIlM9 � <br /> ENVIRONMENTAL HLAL11I bIVISION <br /> �. UNDERGROUND 3I'ORAGE TANK WPOSITION TRACKING RMORD <br /> T..a.trrr*aar*r***i*.r,ia*a#*i4i+++w#}k*#iM1i+.L+�+##i#.k+*4#A!##4}#}}#�###}ii}}#ii}}1.#i�++�kj##}4ii#s+ia►arrir+ ' <br /> SECTION I - Public Health Servlces l nvirvtitntnta! Health 1JIVIA10 f tihk ttficklrig Shbff shall Actdihpany t*ch fAnk affixed with <br /> its site Identification number. The Tank Trackittg Sheet Is Id be ttWhed Id Publid Health SeWlces l aviionmental Health Division <br /> _within 30 dans of acceptance of the lank by&disposal or tet yclirtg kcilit)►. `I1tZ plttnl!ltoldlr 13 tt-spottsible fof ensuring that <br /> this form Is completed and returned. <br /> t <br /> FACILITY NAME: 9 h n sit W nCj <br /> FACILITY ADDRESS: x <br /> TANK ID A39 • TANK SIZE: PPLMOUS'1•ANK CONTENTS: <br /> ...r+.rrr�***rr*�*�*}*ai+***�+i#*!}*#;4*4144*iai1+#}1�#i#i###�M##!1!lie,i#iliiliilii#ai#iiiiiili•iakarirk+aaa* <br /> t 5FC17ON 2 - To be filled out by tank ternoval tontractart <br /> i <br /> 1 Tank Removal Contractor: Z 4 ~' � <br /> I r` <br /> Address: Cfh':- 14LAl�h la ZIP: SaPa`L <br /> bait Ttnk Remove , -=� q <br /> •+•++.;.rrr*a+roc*r+ar*****r**++iaaa*ail!**ar***i}.A4#ii##11111##ilial#iii*4111:1}}iiia*iiaai;+ia+ii+*ia.+i++a <br /> S -C TUN 3 -To be filled out by omitittot "decorttAtninatlttg tgtik"l <br /> 3 w ,;r'4.. :,• .��., i"'S' Sjy i'• •.rye '•- - � , <br /> lark Decontamination Cantractoi UC <br /> Tess: Cita ,. 11 U Le tip: <br /> Phone <br />' Authorized representative of contractor tirtityltig thtough tlgMttittt beltidi ihat the l 6A Wh 6bfilatninated til ass approved <br /> manner equ red by Cal 1✓PA. <br /> Name: L Talc: [tutt,t#r,i. lgtttttt!! l�ateTl I8-4 <br /> SECTION 4 - To be signed "s•� �- -�: .7,-mow. ,. _„ :,.,,,..,.,,�,..�. <br /> and dated 41y ad t#tttlitlkt i'l� fi#k#�iig'S Ah tlstltlft ih1j:lll Mj i of tll3 al facility <br /> - N - <br /> acceptin%tank an of pi frig, <br /> k 4 Facility Name: A c0�rQ C <br /> /Address: "' dPy city .. ttw d Zip: 6FZ3 <br /> Phone A: (.l r u IZI_`_ i��l„� — ---._.,__...— — ---•-----_- -- <br /> i <br /> Date Tank Received:• <br /> 1 <br /> a i <br /> _ r <br /> me: <br /> aIe <br /> l' <br /> •.#+♦rrr*rrr**r***a*+i+i+i#i+##+#!#+#+iii#**}i#}i}i#�i###4i#i}#i�}#}}i#�k}ii#i}}#ii#i}aa}ia}iaaiaaa###+a*a <br /> 23 415 (Revised 10119/96) PAge 10 <br /> f <br /> f <br />