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SAN *QUIN COUNTY PUBLHEALTH <br />ENvUtoNMMNTAL HEALTH C DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACIONG RECO%1 <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: QUI LG- s-(�o P I (_ <br />FACILITY ADDRESS: 10 30 S ®u vE -P,\1 ST -1- CktE*J c"E 9 S 7 `5' <br />TANK ID #39 - �'TANK SIZE: D, 000 PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: WAL-'Ong &_N /0JW6 l /JG <br />Address: PD 50-f- toz� City: D), 5A e_70 Zip: f'15611 <br />Phone #: (q `(o ) 3"J-5-11 (o£3 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: V/, L rcv4 GIN /ry U l NG <br />Address: <br />QUX (SLS City: W, 5!4�C-r-c, Zip: <br />Phone #: () ®i 2✓ _ l �� <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: <br />Tide:——Signature, Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: JKJe$-r C opaS 7' Eta Qt P C4W7 <br />Address: /6-4-0 W . L, M/u/ City: ru a Co Ce, Zip: <br />Phone #: ( �) �v 6g - 3-7 <br />Date Tank Received: <br />Name: Tide: Signature: <br />EH 23 046 (Revised 7/10/96) Page 10 Cad <br />Date <br />