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12/18/98 FRI 09:33 FAX 5106096304 RHL DESIGN GROUP 4->4 RHL PETALUMA Z011 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRAC104G RECORD SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: TFXP►G 1D FACILITY ADDRESS: 4 O IN. G1n4 r k e,, Wa4 TANK ID #39 fors-p9 TANK SIZE: I2,(700 PREVIOUS TANK CONTENTS: 6A%yLjrlE SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: K• ,E c,.-.rn" ks C 0 r\ Address: t ` o() 0L1D COnejo RP City: Ue;06%Ae Q✓ ip: q 132 b Phone #: (9 I b ) 6 $S S$ Date Tank Removed: �s sM*k ye**M*k+K ae**olcY,nk�k*k*+kKkK.K+Ick+Mk Ic�K*Kk+K**kF*K*•k#********k*t*kk**k+k•k+K***tk Mt#**tk�kk*M+M k W*+k*K+kk+K+M+KkK*K*�*.K**M+K* SECTION 3 - To be idled out by contractor "decontaminating tank": Tank Decontamination Contractor: Crosbt„ 4 Over. --o,, Address: `��!3D mek�a ST. City: Oa V ka nv zip: '1 y�Z I Phone #: f rJ I 0 } Io 3 3- 03-6(4 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: C Coe*�j Oy 2tr Tyr\ Address: 0010 ST City: Law& Bock, zip: q b$13 Phone#: ( 5L21 Date Tank Received: Name: Title: Signature: Date EH 23 046 (Revised 10/19/98) Page 10