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SAN J•2UIN COt1M'Y runl,IC IIFAhT1I SF,RVICES <br /> FNvlRONMFtlTAL HBALT'll DIVISION <br /> UNIIRRGROl1Ni/ S'FORAGE TANK DISPOSITION TRACKING RECORD <br /> a•♦♦11+r+♦r•♦r+♦r+♦♦♦+♦sass♦f•♦wr•rrr+!♦+r+♦r♦lrrrrr♦a♦rrrrrrrararrarrrrrNg4rrra444444rN/444M444444N <br /> ^Et't11tN I rnlroc Ilcalth Services Eovhonmortnl Ilcahh bivisinn'1'ank Tracking Sheet shall accompany each lank affixed <br /> wldr h+ site IdcntlRcnti nt nuudrer, 'lite 'I ank Tracking Sheet la nr be temnned to Pobllc ileslth Services Environments) Health <br /> Nlvlsinn nitbdn JO days of acceptance of lite mnk by the disposal or recycling facility. The permit holder Is responsible for <br /> emorbng flint tidy form Is completed slid returned. <br /> Van De Pol Enterprises E,h.A• E CAC002102104 <br /> EACII.1I Y NAMI;:____._ ---- <br /> I'ACII.IIY AUURES.S: 3230_N_ West Lane , Stockton , CA 95204 <br /> Gasoline <br /> TANK IU A'19 - 1-2.81--D I TANK SIZE:_10 000 g�AFvIOUS TANK CONTENTS: <br /> 11•••11.1+.♦♦•♦♦r♦♦a♦!rata!♦+++says+}rf♦rrF+Fa♦r!!ra•rrrrrlrraarrar♦rr+arrrrrrrrr44444444441�1 44444444444 <br /> SECIIII)N I - to be filledoul by lank femoral conitaclort <br /> lank Renorvnl Coalractor._ Jlntt 'llt2LP0 U11, ltnc• <br /> Y <br /> Cit Lodlr CA Zip: 95241-035'1 <br /> Address 35.1_N.._lseclunn_Rd,/1'•U. Uox-.f5:L----• <br /> 3GE3. Ga5 <br /> bate lank Removed: oz� I <br /> 1114•allV•♦♦a♦♦♦♦♦♦♦+♦♦♦♦♦a!!a!!r♦♦+}♦+♦}+++♦al++++♦a+}ra♦r♦rat}r}raarrrrrrrrrr4rrrrrrf44444N444r4444444r4 <br /> SEC'110N .I - to be filled nut by contraclor "decontaminating lank": <br /> lank Itecontmnlnadom Connector: Jlnt Thorpe 011, 1tic. <br /> Loll CA ZI ;9524t-0357 <br /> Address:_ 9ii IJ. Uecl<ntan Ind./i .0. Box 35-1 _ City; r — P <br /> edfyhtg duorrglt signanrre below that the tank has been decontaminated In an approved <br /> Amh nhr,l reprrarntative of cmmacror c <br /> manner as required by Cal EPA. v <br /> C Is MR pp/J 2 T'llle: NR eJ Signature: te0 <br /> 4 •ar 1 1v• 4f#++r•!a♦ ♦ ♦a rrpl$r lrf ♦ a4yt rr♦carr +array/rrrrrra'1+rrrfAr �rrrryrr 4r�►C♦�rnyl+tr1e14♦ *r'r4�**4444• <br /> S�:f��ItONSd rafell hr tlgnr lra{I late�l try <br /> all( <br /> lfi�1�ed rirtieHenla�lie otitic irealm�nl�slola�e toiAllpol�r�Ili�Qe <br /> accepting lank and/or piping. <br /> nclllty Nnnre: Sclutl.t.ze.r Steel I'ror1110.9 <br /> 11,1ncho Cordova, CA <br /> 12000 FOIScrn fllydl Clly: ZIP: 95742 _ <br /> Addreee: <br /> Phone ( `� 1G _) 985-4010 <br /> bnte Tank Received:--.-------.�JY/ g.--_- <br /> / � � <br /> T'ItIe: OQg(los4u s Signal bete-2-,1.7 ' <br /> ♦r.1♦.r1.♦♦r♦♦+♦♦♦+♦♦♦♦+a!!!r+♦♦+r+♦♦♦♦♦+r♦!rr♦♦♦}♦aar+ar♦ra++r♦!}}aar♦++arrarrraaarrr}}♦araaaaafarrrrarr <br /> Pit 21 0,10 (Revised 9111/9111) Page 10 <br /> I <br /> i <br />