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12/18/98 FRI 09:33 FAX 5106096304 RHL DESIGN GROUP RHL PETALUMA 12. 011 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: TS— Ac <br /> FACILITY ADDRESS: 4 4 O 14 . Clea r k e,_ Way <br /> TANK ID#39 - TANK SIZE: I C',T C> PREVIOUS TANK CONTENTS: 17O\501.1n1>; <br /> SECTION 2 - To be tilled out by tank removal contractor: <br /> Tank Removal Contractor: K• 1E Cup�t5 <br /> Address: (400 OL'D ConSio VZP City: Ne>-bu.r ar ip: q I32 b <br /> Phone #: 1 I b ) —(�60, $S Date Tank Removed: <br /> •M�Mk k y*#�*+K�*�ak a4#M+K##K fkM###k###inF##aFkx#*#�#a#*##**#*$yc�cac+!c+kR kkfi#*#+Mt*M*r fit#ft###'skk##M#####Kk+k##W.*k#fie#�yc#**�+k# <br /> SECTION 3 - To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: crosb�, Over�Un <br /> Address: `��3D rlNek1g ST. City: O« klano Zip: °/4'�Z� <br /> Phone #: t I'0 ) l0 3 3- 0 33�, <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment. storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: C�('us b�, OV e.r TO r, <br /> Address: 0030 Wl 044 % ST City:_LONc Beoa., Zip: b�13 <br /> Phone #: ( SLI-) x{32_ S `f`{S <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ##k##YY+k#k###RK**���sM##:�kF#*##*#FMF*##*F***##*#fi*#�'#Kfi*FkK*ak�kKkh*�k�k#*k+F*k•k+k##F Yvkk#kK+ki�k#k*M*M*#+K+KItK <br /> EH 23 046 (Revised 10/19198) Page 10 <br />