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SAN JOAQUMI COLiti"I-Y PUBLIC HEA.LTH SER CES <br /> F,—,rjRON-,,fEENTAL B:EA-TH DIVISION <br /> UNDERGROUND STORAGE TAINK DISPOSITION TRACKING RECORD <br /> r+s#ik:�►,�:*+r#rk=.:srww::*�Y:�u*er*�.tiX=�sisr.�#r:.rfwr#ssrr:=Asx==sr�si#*r,K�*rr#r#r�+kw+k*ak*,���=##ir�,.�s=�.�r=arrr#r.k <br /> king <br /> heet shall accompany <br /> k affixed <br /> SECTION 1 - Public Health Services Environmental Health Division Tank <br /> Tr to Public Health Services Eav ocnm nnal Health <br /> with its site identification number. The Tank Tracking Sheet :s to be r -rnc permit holder is responsible for <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility_ <br /> ensuring that this form iscompleted and returned. <br /> FACILITY NAME: We-S <br /> FACILITY ADDRESS: SZ�� F <br /> Cf f <br /> TANK SIZE: I �j PREVIOUS TANK CONTENTS: <br /> it <br /> TANK ID 39 - <br /> fRrf[iii at ai=yiti ill iaY=aY XJk=s,1r <br /> i[fk=trifi lY iiftir Y.X.Xrrfra=XFris X==w[rf[si[Ysria[rYlifk]ia[i]kri=if4X�i[Rat i[i[riXfklcf[%=r*fk llt tXrYkrlRr r==X�f ieXK <br /> SECTION 2 - To be filled out by tank removal contractor: — <br /> Tank Removal Contractor: LJ G E <br /> l <br /> City: <br /> Address: <br /> rte _Zip: "2 7 <br /> Date Tank Removed: <br /> Phone -. ( � •�) y �� ` <br /> ••• rsr WiXKiis i*kXXis XY[Fa..X�ifrr][r Xriit�lfi='ArY=r rvriwXr <br /> ln�r=krr Yirti rRw XriifXr=ryl a(ailkrtiyi�rrir=r=Xsls=r r+trRrr*i[Rr= <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination C0ntr2c1or: <br /> zip: <br /> Address: <br /> Prone <br /> g through si°narure below that the tank has be-,n decont:�inated in an approved <br /> Authorized representative of contractor ce�isyin <br /> manner as required by Cal EPA. - / ' <br /> I �,.� Date CLQ /S <br /> Name: (i('� <br /> Title: � `'2 �5'* Signature: CL <br /> XXXXiX.Xri.>>[i*klX fki X===iris:x#rLt[Xir=ki[Xr:#wr*R,.r.�Ki=r.�fF�iiX=>=#=rte��or e" aciiity <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, stor�tr ispos�s� <br /> accepting to/`nk and/o J�� <br /> Facility\Tame: feSr �/ <br /> Address: / �%v CtTy• <br /> Phone #: <br /> Date Tank Received: l � <br /> to <br /> ` / s <br /> le: Si--nature: <br /> i fki i�yrsirti�r#sr•tiwsrrai#T*MXi ifrrw X�XrksisXri#sw�MFrw�rr Rf#iMlkiiMWYXtik# <br /> Mir in*=ar rtii�**ris fa XMr,�ri�!i#F <br /> tri <br /> EH 23 045 (Revised 7/10196) Pate 10 <br />