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12/18/98 FRI 09:33 FAX 5106096304 RHL DESIGN GROUP RHL PETALUMA 0011 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TAINK DISPOSITION TRACIUNG RECORD <br /> SECTION 1 - 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: AGo <br /> ,1 <br /> FACILITY ADDRESS: `-1 4 O 14 . C V\a r k e,. Waq �± <br /> TANK ID#39 - Q _S TANK SIZE: I�, O0p PREVIOUS TA1INK CONTENTS: GAS0LjAiE <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: K• 'E C,\.w-tS <br /> Address: V4 OC) OLID COnE_jo JZP City: Ne_K)b , Qr ip: 671320 <br /> Phone #: (9 16 ) 6 $S S Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Cro,5%, Oyet�-on <br /> Address: Nyye2tlg 'S-c City: Oct klano Zip: 3141�2,I <br /> Phone #: ( 5 I'0 } io 3 3- 0 33 l,, <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: CY"uS6.j Cy erTur\ <br /> Address: to10 W, 044 % ST City: Law6 geocL, Zip: ct b�13 <br /> Phone #: ( SL21 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />