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01-02-1997 11:2041 FROM S=MIO TO 5aN MATG2 P.01 <br /> S�'70AQUU;_COUNTY PUBLIC E ALTH SF- 'ICES <br /> LN-MONMENTAL HEALTH DIVISION <br /> UNDERGROL:YD STORAGE TANX DI.4POSSIMON TRACEONG RECORD <br /> swwww+rrrlww rwa�rswwrrrwau�w W+sfYfYww+hr'#MFR7.rs1r*lw�kwW W+�kr•saewwwaa�ifpwrY�.Y�W+YMr+Fr W wwwlaa�a.rFe Wns�.w w w NM+f s <br /> SECTION I - Pubiie He91th Scxvi=EavimnQ4acc1 Health Div-Esioa Trak Tradcbag Seers shall accoa parry eacb tads afaxed <br /> with its sire id_-mf&cadoa member. The Tank T rae'.dag Slums is to be r-:used to PsbUc E calrh Sc vices Eavim-m-lul Reatcil <br /> Division within 30 days of accgraace of the tank by the disposal or rccyc!Ing fclisy. The pa it holder is cesgoasible for <br /> e= ring chat this form is eomplemi=4 ratexned. <br /> FACILITY NAME:_ �ol�/ f��Z Cb. <br /> • -- <br /> FACILITY ADDRESS. �f 1 Pew DR-• Timet~ <br /> TAINK M #39 - TANK SIZE: .'0 SAL, pQc V 10 S TA..NK CoN-rYrs: &A-re 0/i <br /> err W yrWr�rw w+r�ww�aw w whW err W r+Yl,�aY+a W*wsw4*wwwtrwWsisa Wrs�*srt+srrssrswawl+rwia*#>�aa�sW W�rrn.rw�rr�rrrra..r rrrw w# <br /> SECTION 2 _To be Iced ore by tank:®oval contracsor. <br /> Tank Zamcvai Conu or. = <br /> Address: 1 717 S. 7t-h Strut _- _-- • _City: Modesto Z17: 95351 <br /> Ptone- 209 524-9653 Daze Tank Remove!: 12_q- <br /> �*wW:ewer W W wwJ�WY+M rafrrWrs r�rw carr rrwwwwlrww#r*Fwyrrle+Yrpswawsawr+rrwrryrrrwwr�Rww�IrYriawssws3swy.rrarrwrti�r w.r r#s r rr <br /> SEMON 3 - To be 511ed Qct by contractor "decoutmimating tank": <br /> Taak Deroc: mhu:ioa Caaaaccnr: M4M <br /> Address: 1217 S. 7t:q S_reo-t Cirf- Modes to Zip: 95351 <br /> ?tote 209 ? 524-9653 <br /> AuCIL 'Zedr 'res=t=ive of:Cucr=cr=mfying tl:sousb sigt==.below than the caws has bees decc==:eated in an approved <br /> xam;er as is fired by Cal EPA. <br /> Naa:e: Gly- Tile: Sigaa=c: Da:e-i�•'�l-�7_ <br /> rwwr wrw.r w#4 wrrwwr#wl�wwwtrw#�R*w�wwswr W w�rw+WlyrW W rrrrrrrrrwrrrrwsrrw,Mrsrr*yw�l�lFSY+HI+��Fi�rr�aa'a�w�rwrsy.+.:r s v rwr r <br /> SECTION 4 -To be signed aad dsrd by aza aatharized reprmem:adve of fie a=cmw==rage,or disposai faciiiry <br /> =qc�mg sacs andtor piping,- <br /> FidUry Nat: Mc desto hunk Cormnv <br /> Address: 1403 4rrt Si rpt -- City-, sto Zip: 95354 <br /> Ph*=1: ( 7n4 ) - <br /> Dace T=k Received: A <br /> tame• Tate- Sig�amre: Dace j' �` <br /> weer rr rwwrrrswiswwwrrwwwwwwyrwsrwr wwtrwswwrwa�+srrwrrariararrasrr.wta�r+wrrrrrrrpw*rlrwarrryiw*w�swwrrraraarrrr <br /> EF?23 04.6 (Rav,.7*d 711066) zee to <br /> TOT4_ P.01 <br />