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08/29/2003 FRI 05:49 FAX 661 393 3834 MP ENVIRONMENTAL-BAS 0004/006 <br /> May-22. 2003 4:16PM Gla, : ,r Environmental No-0354 P. it <br /> SAN JOAQM COUNTY PMLIC HEALTH SERVICE$ <br /> ENVXRONi4MNTAL$EALTii DIVISION <br /> UNDERGROUND sTORAGE TANK DIBPOSMON TRACKING RECORD <br /> `+rWWWrrr®•armmrrM•r■YrwWWtY•r•wra8r#*WE rpaWtllrYr■■WWWWaaarraWWa4e■rrWWwrWr6Wrrrararrryrr•'prrawwWrrI•r�ww <br /> SECTION I-Public Health Services Pavironn ental Realth Division Tank Tracking Shr:a"acoompaay ea&Unk tf'lxed with <br /> its site ldemilludon titunber. The Tank Traeklq Sheet V to be returned to.Public Health Swvkcs EnArournac sl Health Division <br /> wlrhln da of accepranoe of the tank by the dispose!or reeyoUng facUity. The persalt holder is responsible for msuritS%bat <br /> this Perm!a sompheted and returned. <br /> PAGIL.TTY NAmz: '7— a 4,. < AL3 — Sate zA <br /> FACILITY ADDRKSS: Z-S <br /> TANK ID 639- :Z57'Z.O('o TANK SI$E:® 101( wo -'RBVIOtIS TANK CONTENTS; G-4�. I <br /> #eaeMr�►er■w.�rrwwaw•ar■rrtrrrw►w•a•#Wrrrraa♦•awrlptr+#rW�FWwWriiw#riawrtttrr+eipwWrrM•a■serw*Wrrrwtirwesrit••r <br /> SECTION 2.To be tilled out by lack removal contrsotorc <br /> Tank Removal Contractor; <br /> Addrm.- 04(D i4,s 1<c�I <br /> Clty: 2r1+./tr/ <br /> Phone iv:: Y>"5' 2 !c, Data Tank Removed: ^ <br /> rrwe•r®®■*■rrrrr•ia*rYr4r,Www*rwrrrwM*•Mw#4•tre■M4r�w*#q#My.prt#ti*#air•rarWrrtmrMrr®wtcwrw•`rMywarbrrrAee■tor®a <br /> BECMON 3-To be tilled out by contractor"decontaminating tank": <br /> Tank Decowaaftation Contractor: <br /> Add City: &/me.-a l zip: 'F <br /> Authorized repreaantadve of contractor cert*In$throuph slgnatttre below that the tack has been dawwAxln W in as approved <br /> meaner ae mquiredd byy,Cal <br /> _EPA. <br /> Mt�I#arWrrpp■•pllrrrrer••■rar■s4ae4wWWa*wrWiwr•rWyf■Yr♦Wwwrrrbrrrr`tWNPM*�t■rwrlps`#dWI��IWIp*iM+Y1YWMr®•� <br /> REMON'4.To bo t! and dated b an authorized r trttapswt. <br /> $� Y erit'raentstive of the treasmprt,storage,or dlipaeal ihasyi{y <br /> accepting tank x/or plpiag. <br /> Pec My to me: <br /> Addiva: b'k,U a3- LIU -f u� <br /> Date Tek,�P=elved: d d <br /> Nx= 'gau,(D a- )aLTide- <br /> 1C�s sigzran� <br /> tr44a4M*4*4•�#Af4�are•••r•rewr••••■r***4a4t44P•etw'rrplprrrwrwr#�#Rti#fie•Radars■®aeres■■er•®'�p#4#r#R�tsrr#! <br /> 23 Q46 (kcviscd t?8113l44) Page 10 <br />