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Jul . 13. 1998" 1 : 1IPM1 "'u"209-9^ -5059 No-4296 P . 2~ ` <br /> v <br /> SAN JOAQUO COUNTY MLIC MALTH SERVICES <br /> HEALTH DIM(P- - <br /> •ra•rtrrararra•r•••rrrrr•rrrrrrrrr•rrarrrtrrirrrrrrr•rrrrrrrrrtwrriirrtttirtrrrrrrrrtttrrrtMrrrrrirsrrr <br /> SECTION 1 • Public Health Services Bovirvtunente Health Division Tank Tracking Sheet shall ac compmy e0ch tank affised <br /> with its site ideatiftcadon number. The Tank Tracking Sheet le to be remraod to Public Health Smicas Environmeate Health <br /> Division within 30 days_of accsptam of the tank by the diad or m cUq Wility. Tho permit bolder is responsible for <br /> eoaumg that this foram Is C*Wleted and raurned. <br /> FACILITY NAME: Sma K—m 'j'-)t0_YE.\e►.o Ua,t7 Tn Lr• <br /> FACILM ADDRESS: <br /> TANK ID #39 -� TANK SIZE: )PREVIOUS TANK CONTENTS: 1 <br /> trtrwrr*rtrtrritrrrrrrrrr•srrrarrrrr+kr*rtrrrrrrrrrrrrwwrwr•rrrrrrirrrwMMMM+►+trrrtrwwttrwirrrnYrwrtrrtrr <br /> SECTION Z -To be filled out by tank ren*vW contractor: <br /> Tank Removal Contractor. ,QM ( 'D/lt of f c e �I Q _ <br /> Address: {✓ l -f City:07 "C) 1OAI Zip- <br /> 'n <br /> Phone#: (a-j3ca, ) 9v G Dau Tiraic Rsmaved: <br /> •trrrrtrrrrrrrrtrtrrrrirritrttr/rrrrirrrrtrrrr•rrr+rr*rrrrrrtriarMttwttwM«itrrrrriti••rttt••r•rrtrrrwrrrr <br /> SECTION 3 -To be filled out by enc actor "detontamiffitw=tank". <br /> Tank Decontamivadoa Contractor: <br /> Address: cLty'-- -- Zip:" <br /> Phone F: <br /> Authorized represontativc of ecatraetar cer*ing through signature below that the tank has been decoatamirlated is an approved <br /> psaaaer as required by Cal FFA. <br /> Nam: Tide: _ Sigaunua= D�..i, <br /> wrrttaatrrrrirrrtttrrrrr•trrnrirrwrrtrtrrtrrrrtt+rararrrirttrw/�Mirrrr•r•raarrrrrrA�rrriwta+ar�rr�rrrrr. <br /> SECTION 4 - To be signed and dared by an authorized repos mtaUve of the,treumeat.st"W,or dLvmd ft cW Y <br /> accepting tank and/or piping. <br /> Facility Name. <br /> Address: <br /> City C � -rc Zip: <br /> Phone N: ( tt ) <br /> Due Tank Received: <br /> Name: <br /> Title: Sag�satare: Due <br /> rrrrrrrrrr+vrrrrrarrrrr••r•w«»rrrrrr.rrtsr•rrrr.o+rwirrrrrr*rrarrrrrtrrrrarrrwr4wrawrrwwrMMs•tittwwwrr, <br /> EH 23 046 (Rovised 7/10/96) Page 10 <br />