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MAR-18-99 THU 05:54 PM P. 03 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH VICES' <br /> ENVIRONMENTAL HEALTH DrVISION <br /> UNDERGROUND STORAGE TANK DIS ON TRACEM RECORD <br /> SECTION 1 - Public Health Services Evkom=uW Health Division Tank T=kmg Sheet Shall sCsotnpatzy vetch tank affUed with <br /> its Site xjc=f=jon=mbcr. The Tatak Tracking Sheet is to be rerazed to public Health Services Environmenmi Health Division <br /> within 30 days of acceptance of the tank by the dispoW or recycling facility. The permit holder is responsible for easuring that <br /> this forst is cotupleted ad tatttrncd. <br /> FACIi=N,AME: LI U IR! <br /> kCU-ITY ADDRY-W- V 1Gaff= W21 �W <br /> TANK M#39- t) Z 3 TANK stZF_ ISP,M J%70 PREVIOUS TANK CONTENTs:1Sf//J� <br /> WASM oft, <br /> SECTION 2-To be filled out by tacit removal contractor. <br /> Tank Removal Contractor: f2s 7l 50 Me CH <br /> Address: ;j S ST- _ Ci: zip= . <br /> Phonc t: f 0510 Date Tank Removed-. <br /> SECTION 3 -To be filled out by or" tank": <br /> Tank Decontamination Contractor' `� 4 <br /> City: p L ZIP: <br /> Pbow <br /> t G? Q 3 <br /> Authorized ve of cowatwr certifying dtrough dp2mm below that the tank baa been dec ted is an droved <br /> manner as required by Cal EPA. <br /> Name: Tide: S' Date <br /> SECTION 4-To be ftzd and dued by an au thonzed reWesmtWbe of rise .or disMsaL facility <br /> accepmag tack or piping. <br /> Facility Name: Le I <br /> vr? 1c, M Zip: <br /> t none <br /> *: t 235 I��3 <br /> Date Tank Received: <br /> 'Name: rule: Date <br /> ER 23 00 10119/9$) pap to <br />