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Oct 01 03 08: 10a Carrie Brown (2091 461-6342 p. 2 <br /> *^ 01/16/2003 09:29 209468mpd3 FIFTH FLOOR PAGE 13 <br /> SAN 1OA,QM COUNTY PIIWC WEALTH 5ERNWES <br /> £tNV1RChNNf:NTAL HEA7„TH DIVL%ON <br /> UNDERGROUND STORAGE TANK DISPOSMON TRAC WG UCOn <br /> a'azx•a,r*rs►rar*rr•*rr♦wraa**4-*V*wraxar rarzraa*rrrr•*as*wss.".z.**MarrgA-*Klk***Mir+w-p*+ra*wrrr PDX t r041aar*** <br /> $E.CI"ION 1- Public Healrh Services Environmental Mmdth Division Tank Tracicina Sheet shalt accompany eacWtir&k afted w,it,h <br /> its site identification number- The'T'ank Tracking Shcct is to be retuned to Public Health Services Eaviroumcntal Ht:@ b Division <br /> within 36 dans of acccprance of the Lank by the disposal or recycling facility. The permit bolder 4 respotsiblt for ensuzing that <br /> this forth is completed and returned. <br /> f FACILITY NAME: ,r� / u t [ v <br /> JN PACiLCI Y ADARI SS: C I I 3 . A_W/L 6 .S �f� _ _ g`�1.z <br /> !! TANK ID r39 Z SO TANK SIZE- ,'�0 o c PREVIOUS TANK CONTENTS: kf � <br /> ras.*+*s=rv.Yraat*tar*sr*iaa:rsr+erirr♦awryrraraxzrrrarrarwatrrrarrira*rr***•**r+r4rr*►##w.►*:**rM*♦rrrarazrrrrr <br /> SLC IO i 2-To be filled out by tank removal contractor: <br /> 'yank kcmoval Concractor.� � /. T'�. �— C g_ J <br /> Address: ? s' srl, G' u-,gr - City: S Z—A-P , Zip., 9-C'�Z0 <br /> Phone A': (_.20�l C�l !o Oxe Tank Removed: j c c--2, <br /> +#zrw�4rrr�r�w*r-rrtr#rrr.w#air*.rlrNr#r•rax*�**rrrrararrrrrrr*rrw*s*��q:rkRaaYF4irawr*�rrrwwrrr***wrlr�rrYrrsr <br /> SECTION 3-To be filled out by contractor"decontaminating Luk": <br /> Tank Decoputmt Ration Contractor- C71J M C � <br /> .IV " - L.- -- <br /> Addrrss:,P. �C _4 W,Q I _ _ _ City_ So;C/ <S Zip: _S <br /> Phone I: (3-1-6 3 7i <br /> Autborized representative of contractor Certifying through signature below that the tank has b4ma decontaminated in an approved <br /> omanncr as rcquircd by Cal EPA- <br /> Nzmr: , y?z.� 7_ tle: 1 �c 5ignaturr_ Date <br /> :r*tett***rr.+sr+rrw*Marr*�.r+*wry#err=r?s4rs++=,wrswrrssar....rant#rf+f*ry*syr+aastrtrrrrstier+*wSrasywsr*rrxrlr* <br /> SECTIO;!4-To be signed and dated by an authorized representative of the treatmc=[,storage,or Wspasal fatilky <br /> accepting L-k_a-Wor piping. <br /> Facility Name: <br /> Address- 1 r „3_ S ff A (t1 -12 city- S' /lN Zip: <br /> 647— 933 7 <br /> Dam Tattle Received: 2 ' 2 c o 3 <br /> Name: Date <br /> *rryzrMr art;r+r*.ra rxwxrr z•w*ri+a r ra*##�,ravxr rrrzysfarr err*>trrr rrrra�lrrxMkrrr#�:Mi#*►arixrrix*rM�r!'r♦*fi�zrw <br /> EH 73 046 (Revised 0XID/99) Page 10 <br />