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_..A-, .. ...-..,,. .WEST_-C.0fiST. .EQUIP SALES 1...2137 66S 93132. P. ra1., <br /> �. %-TJ It. <br /> a <br /> +1 <br /> I <br /> rr. o;If96 Till I.,t:J3 FiX 208 467 1116 <br /> i <br /> SAN dOAQUM COUNTY p'CMUC HEALTH SERVICES <br /> ENVUtCe MENIAL HEALTH DIVISION <br /> UNDERGROU.'KD STORAGE TANK DLSPOSI7ION TRACKIl4G RECORS D <br /> •:rri ssrrrry rsa•.s+srrtsakrsr>t+k}irii#ssrisii to*ir ri*itrri#!.#s#r#iiil:t#i+r rrrr.r�aw aF*#sro.r w.r ri.Fri rrk.f,Mxsrw.sw.....:..v <br /> SECTION 1 - Public Health 5ervites ftvironmemal Health Division Tank Tracking Sheet shall accompany each yank aiftxvt <br /> wirh its site idzatifteatim number_ The Tank Tracking Sht*t Is to be Mfurned to Public Healtb Services EuvironrsN_-n al Herd <br /> Division wirthln 30 dare of accseptaact of The tank by the disposal or recycling facifry_ The permit bolder is responsible,c <br /> cmu i g that [his form is completed and rt u mtd. <br /> FACILITY NAME:_ )UA-rag6u <br /> PACH_r Y ADDRESS <br /> i <br /> TANK II) #39 - l USI-Z TANK S=. Zf PREVIOUS TANK CONTENTS: t <br /> .tl mars si+`ias};,�rsirrsasiiiir7 i�rrr*ii�FhrrrialrifWYiirr�.rrrrRrrrrrrrrrsrrryrrrsssrrrr*�latrsaswv,e--wr.w.,.r..: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> I <br /> Tank Rtmoval Contrarctor: c. <br /> Address:--Y WAY Cir : 57-bgjl�&i —zip: 9�5z o5._..,...._. � <br /> Phone 0. (��_) '7 - /CDate Tank Removed: �9• �� ����_ ._ _.� <br /> ..ris.sats:rs.arrM,r rrrrrrrrrsrirr,►..rtrsrsrsrsiralr�srr+F arissaks.rrsi#ii#rirar►r rrsrr.%.afr mfr ia►r a.r�rry.#arssar,.�.a.�.�--. <br /> SECTION 3 - To be filled out by couzractoe'decontaminating tsbe: <br /> Tank Decontamination Coatraetor. C N A� ,.„. ..:•__._.____._. , <br /> Address; W n City:-7:jrrOC��0/1_ - Zip:9 5 zQ«a' <br /> Leo )Q <br /> Authorized representative of contractor certifying tbrou9b siz-rxatnre below that the tank has been demnuminated in ant agpru �... <br /> manner as required by Cal EP.� /` f <br /> Naux:_ l j r'10_TW' C,stie- OCOY a! .�7SigaatYue: Date /'Z-0-3 - <br /> ►ri*fi*;*:,I,yiyi*rits4.Mriwrr##*srwirswy iarsy Kr+iilakisars W►#iirktiW si+X.sss+sa►rrisrakrs:a*#*�aW <br /> SECTION d - To be signed and dated by an authorized reprtsentadvc of the trraunew. storage, or disposal facility <br /> atxepting tame a9dlor piping- <br /> Facility Name:��S T �7 <br /> Adk rcss: - tet' _ _ Cky_T rice p� zip: <br /> Phone 0. ( Z ON <br /> Date 7'aalc Aeocivcd: <br /> Name: fGt1 Title: !� l � z3c—g <br /> - <br /> aaue. <br /> ksiirr.i•s#srral..�srssisrrr#fialnYass*sssiiiiissssisr ss Iwo rssr*siii###sr#rrsa��is�rrwrr rsrar�+wii_ .Ww..M.r..y.. <br /> EH 23 Oad (Revised V11u96) Page 10 <br />