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10/17/2000 09:00 2094683433 <br /> FIFTH FLOOR PAGE 1g <br /> SAN dOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • � GETArNNSION <br /> UNIIERGROUNDRAKDSPOSMOTRACING RECORD <br /> Ss site ide k-Public Health Services k riranraesatal Health Division Tank Tracidag Sheet shad accompany each tank affixed wuh <br /> its site eutzfication M=bey The Tastic Tracking Sheet is to be r=rned to Publac Health Servxces Environmental Health b:vxstu <br /> v4ththin 3--- M of ecccptance of the tank by the disposal or recyclmg fac8iry The permit holder 13 responsible for ensuring that <br /> thus form is completed and returned <br /> FACILITY NAME EACIIC AV ---NUE ARCO <br /> FACILITY ADDRESS 642 5— PACIFIC AVENUE <br /> TANK In#39- TANK SIZE- 10, 0 0 0 PRSvIbUs TANK CONI'ENTs- GASOLINE <br /> xw#fir***w*i�#ww�s*�#*#Kw*:w****w*rt�r***s***********#*wok+i***+kw**r.*****�►#+#fa+►a*w#arae*�xK*w�*#*#*w****+�w**M*M*mow#,w <br /> SECTION 2-To be filled out by tatrk removal contractor- <br /> Tank Reinarval Cmtractor: W- A, ERA N . <br /> Addrem 6940 TREMONT ROAD ems,.- QIXQ_N Zip. <br /> Phone# ( 707-- ). 693-2929Duce Tank Removed. <br /> 4+i#wrtrt#*w#w#w####w###wiMiR�M+kww�M#*rtww�e#*y�rtoF*�Ityt�wiiM�MM��InhMt+l�kM##�F*#riM�h�FiM�MMrtM+IM�frtrt#is�kle##dnY7M*�M�R�NM#iPi�wM�R*it+►�Yw#+�trts# <br /> SECTION 3-To be filled out by contractor "decontamit UnZ tank". DOVES r►C5'—', A Q V t`J <br /> Tank Decontamin don Contactor <br /> Omrml Ctty: <br /> Picone 0. i <br /> Authorized TePrCs=tatxve of contractor certifying through signa=e blow that dbe tack has been dectmtauduated in an approved <br /> meaner as required by Cal EPA <br /> Name_L E t A_N D .Y I A L E!. I S Title. Sit t 2 0 C <br /> *rw*wwwwww##wx�*w+�trtrwsw rtsa*#*#**w#**#*�Mt*rtrt♦•�*aer**w*�**w*ww*Kw.��x#�sx�#ria**��rt***ww ww*w*rK*�##arae*f*rt*«*.*�.* <br /> SECTION 4-To be std and dated by an authairh*d representative of the uVatment.storage,or disposal facilaty <br /> zcceptiag tarok And/or piping- <br /> Facility Name- <br /> Address <br /> City' �. Zip <br /> Phone# <br /> Date Tank Receh ed <br /> Name Title- <br /> Signature' 17atc <br /> t�*###*#k#*:w**yesww*w#+M•#MSM 1r�r###arirrr>r#�#rt�r#a►*ar###**��art�**#*****►ww.r*mow*www*r�rNrtrt��rtrt#f#moi***##in#wwww*# <br /> EH 23 D46 (Revised 08/13/99) Page 10 <br />