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SAN Jf`AQT 'NCOUNTY PUBLIC HEALTH <br /> UN-DERGR=eSTOR.A YE T:1NY DISPOSI7701N, a -IMNG -ECO:-D <br /> .x******x><*fete**,w***t,�[lfile*lk.ye*xfetrtx.•t*+ItxW*fe*i<x*+**;.**txwt*lRxftfe*rtxtxxl,Le*x*v +t.e*lk*x*lk.�e**W:x*xWWxlklY yefefefe*.xx*fest <br /> SECTION 1 - Public Health Services environmental Health Division Tan: Tracking t, shall accomnanv each tank afftxed with <br /> its site identification number. The Tack Trading Sheet is to be retuned to Public r Services Environmental Health Division <br /> within 30 days of acceptance of rhe tank by the disposal or nett d ng facility. 7-,e r t holder is -esr�orsiole for ensuring that <br /> his form is completed and reatrned. <br /> FACILITY NAME: �Y <br /> d <br /> =ACILITY ADDRESS: <br /> TANK ID »39 - JC) _{-03 TANK SIZE: ZC PREVIOUS TAN- >NT NTS: � <br /> fe LlW ae***x**List.*Lifel ----.<-- xlee.....>;[ae�txa[>xW***lk.e Wlkfe xsa[x WxW <br /> SECTION 3 - To be filled out by tans; removal contractor: <br /> Tank Removal Contractor;���-/�,'S�0-ty <br /> Address: �SnR /�o . ;e.J � City:,��� '�� Z::;: GS—ZcS,-- <br /> Phone ( _1�{G,CF ? Date Tank Removed: <br /> xl.xx*M**xxWx*l.x;*****xtf*g ***;:***x:.x*x..WM*x#M1 x*:*x,xWsx*L-.tx .xW*W . . wx <tl:*t:tWM*xxxtW**x***x <br /> SECTION 3 - To be filled out by contractor "decontarninatir; tank": <br /> Tank Decontamination Contractor ,..J S� 1 ��. �•- <br /> Address:-So"" ZC. , t- ASto,+3 -;-, City: Zip: , S— <br /> Phone #: (eo) ) <br /> Authorized representative of contractor ce:'ifying hrougt sir, lmure t"C!ow that "he cry ?s been deconlw=ater in an approved <br /> .n--nner as required by Cal EPA. <br /> Name: Title: Siznar'e: Date <br /> <ettxx*Le*WMM*l,el.*Lt*WtlKx*let lint*veWx WtLt+le ye fe**l!e[e lkxtyx,te:M*file-w*m+i<xtX.>r+xla L<>1e+tY<xMxn .>•.Ltx*hx*ateex*xzxtleet L.:tWW#*xx:etW%l+* <br /> SECTION 4 - To be signed and dated by an authorized representative o:the rrea.. storage, or disposal facility <br /> accepting tank and/or, piping. <br /> Facility I--ell .'- ✓', �.� <br /> Address: r?00 ��b _ W 4+.�1e—L�'rr� _ Cir:: :, ZiP: <br /> Phone -': (Set <br /> Date Tank Received: <br /> Name: Title: Siartarure: Dare <br /> sill[t*aRKIM>!c*W**Wfl[ie***xateee*WWM%e*arx Wlk>Ie*fie ilk:Yx#t*xll[luefel!e*ilk****ftlfle llcaslk ilk*W><*xxxxfex Wls l✓ �'txlk YeXeMl4Wyelkf[ejt*ae*]e ll[fex#lk>telk*;ftix*ilk ilk <br /> EH 23 046 (Revised 1:0/14/98) Page 10 <br />