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9. <br /> SAN.TOAQUIN COL:�I'L'Y PUBLIC HEALTH SERVICES <br /> t _ ENV1RONi=, AL HEALTH DIVISION <br /> L DERGROli°tD STORAGZ T_•�'�fK DISPOSITION TRACIMNG RECORD <br /> .�YxaxmmxsmmmmxmmYxffizzx..Yffixmm sxxYYmmzYaezzffiYffiffiffiffimmzzmmxx xzxzzsYsffixsxaezzzzxmmxmmxxYYmmmmzxa.....s>xzxxxaixxxxxxxxaszzxx <br /> SECTION.L-Public::Czi[ `r ;ices En.rironmentai Se:ith Divisioa Tani Trac,iaz Sheet shail zezo=aay e:c;, tank <br /> wttL Its sire identincarioantunoen Me Tank.Trac,in_Shee.11as to be rerared to ?�.,biic Hezich Serrice,; F:vi.-oma erta? �e:it4 <br /> Division.within M days of acceptance of the tank by the disposai or recycling facdiry. Trie permit hoiden is resnonsibie or <br /> ensur g :hat this form is compie:ed and returned. <br /> FACILITY NAIME: <br /> FACM17TY ADDRESS: Af` 9411 1. <br /> TANK M T39 - TANK SIZE: "7 Cr i" PREVIOUS T:IVK CONiLNTS: <br /> <Y XffixxmmYx Yffi M......mmYffiffixxxffimmx: mmxxxxxx mm-----xxxxmmx.... ..xxxsmmsz........mmxxxxxxxxxxx xxxxmmxxxmmxmm <br /> SECTION 2 - To be ;filed out by tank removal contractor: <br /> Tante Removal Canrr:ac:or: <br /> Address: 7C ("Aecty 4 �!''�if C:�i: N(11.1('; �� % Z:�: > =�r(r." �• <br /> Date Tank Removed: <br /> X]RYffiffiffiYytYYYZzxxffiffiYzzszYY'3S![ffiffiszmmzzffiYffiffiffiffiffiffiffizffimmffixXXxYYXx9tfkXYzsmmYzsffiffiffizsXzxsx Xx xX mmx xs xxmmxsxxxxxx.Xffisxxxxz..xxx <br /> SECTION 3 - To be filled out by contrac <br /> to <br /> r "decontaminating tank": <br /> Tanis Decontamination Contruc:or: <br /> Address: ��' / ' r_")) /��tL �1/ City:� il IV Zip: � J� <br /> Phone �C> �� —��/i�C" <br /> Aurhorize d :enreseatative of contactor ccr:fving trough siS=-,rare below twat she n-' ??S Jen.^. <br /> -:.isle: as .required by Cal ?A. <br /> fame' Title: Signar=e: Date <br /> azffiYzz:zffizszzYaeez#Yfe�sszffiffisXzzsaersezzzzasz:zzYzzzsxxxzYzzYffizsssYYXXXzzzzXzszszzszxffiYYzsxmms:ssxzzs..YYYsmm.YYYssmm <br /> SECTION 4 - To be signed and dated by an authorized representative or the tr-=e=. storage, or=osai facility <br /> accepting rank and/or piping. <br /> Facility Name: _ �/,/ <br /> Address:- ciN:x_ 51 c� zip: <br /> Phoae <br /> Date:Tank Received: <br /> Nano- Title: Dare <br /> SIgII2ItILC: <br /> „�M+k�Bnlea�s�M+M�Irsir+luleaM*�M�kks9nh�d.�Mkeger+asu�lsyeassas�laM+wmeaaraearanh�Iwl.::Yams:®zasasyeas:soon�srrakzalsa�stesk�a�ra+Ya.Yzxaz=vuluu•ffizzsz+P+�zezadzzzzke+Pis�sssks=ec�ls�er <br /> EH ®46 ,t`Revts 9/L T19 Fie L® <br /> �.�., .. 4 <br />