HomeMy WebLinkAboutUNDERGROUND TANK-C-6/5/89 .- FILE CONTENTS SUMMARY --
I,Z~ZT #: 0¥0057 z~v.
Activity Date S Of Tanks Oomments
COUNTY OF ICERN
.. Environmental Health Services Department .~- .
· '2, PERM'rT FOR PERMANENT CLOSURE PERNTT .NUMBER 'A 925-06
~ SUBSTANCES STORAGE FACTL'TTY
~'207 ..34th,.Street ~:,,: ;,~ ,_~,::~~~::P-.,.~,0.~Box 10809 .~,-:;~.,=.~-,:~,,:-.:::,,.~v~.~:~.~-.,.;:,5400 Aldr:
'-~.' ..... ~' ~:.:m~-~,-., ...... ~-----~,.,.- ..... . ........ . . Ltcenee · 520768
:: g:.' *., .J. ,. :.~-.~.,,,,.:.- ..~ ,~.~, . .~ ? ~.- ,... .:-, ,. . . ~ ~: ; . . 'L~- . ,,~-.
.. ,,~ ~ , ~.-..,. ........ ~ ,-. , . .: . ~hone.(805) 834 6464 ..... Phone. (805) ~835~700
PERMIT FOR CLOSURE OF - PERMIT EXPIRES August 8~ 1989 .".-.
Dan Starkey [ . ,
F .:~ t~,'. ~t .':'i: ,.-"+~?,4~:i.)~/' .', t ~:;~:~', :' ~ '~ ,. ,. ' '~:~'-cf',:~ ~:,~.~ ~,
, ~ ............ , ..................... POST ON PREMISgS ..................... : ~ ;, ~,-..'~,.'~; ~'.'./~:.-:-~: '
...... . .... .': ..' . .. ::'--- .~ "~:~::::, .~.'
' ' ' '" ' '".t>.' 't[['::F,:" '" " ',. ' ..... '~'~V:,~::' . 'F~t:'~F:~':"'
--~. "" .... A copy o~ this permit ha~ been provided to the Kern County ~Ar~' Depa~tment.
Pe~m&~tee mu~ no~i~y the Kern County Environmental Health .Depa~men~
' (805) 86~-3636 t~o ~orAing days prior to tan~ (removal) or..:/ne~t/ng and
R.""'~.;::~?~l[Pe~mltt'e~ must obtain n city ~J=e Dep~tnent permit
S.. .":,Tank closure activities must be per Kern County Environmental Health
. :',Department and Fire Department approved me~hods as described in Handbook
PER~IT FOR PERMANENT cLoSuRE PERMIT NUMBER A 925-06
'~'~. '/'.J"J?J(': Any ~devtation [from"'Sampie '-l°catisns ~nd '.numbers" ~or [c0n~titUents ,to'.'.b~
, :.:;'~... ))?'Jsampled for which are .described below and in Handbook ~UT-30 must receive
-~::.J?~:~'~prlor approval by the Environmental Health Department
, ,.'-, ,:?-:,~f,[-~]:L,~:"~f~]~[a, :%'.~,~(Tank size 1,.000 gallons or less) ~ a minimum of two samples must
· "TcS.-~f=~tf4any-contractors.-:or dl'sposal~Facrl-t't~-es-~other-t-han---those-t:lsted on
..'-':,,.::[t&~.~[~[~::'i:and permit 'application are.to be utilized, prior approval
...,, '.'.:.-:,(t?a minimum of two samples 'must ~e'retrieved at dePthS'of approximately":'f~°
' [;~:~.~ee~ and slx ~eet for every 15 linear fee~ o~ pipe run and also near the
8.' :'.['i~iCopies of transportation manifests must be submitted'to .:the~Kern County'
".' ':Environmental Health. Degartment .within five days of '~aste :disposal
9. : :'Al1 applicable state laws for hazardous'waste disposal,' "transportation,
or trea~men~ must be adhered ~o. The Kern County Environmental Health
Department mus~ be notified before ' moving and/or disposing :,of .,any
10. ~f. Permittee 'is responsible for making sure that "tank 'dl~poiitt0h:~*~ia6~ing'''
..... record"~lssued with this permit is Properly filled out and returned Within
11..:.:.[-~,'-Advise this. office o~ the time and date of the proposed sampling with 24
1~. Results ~ust be submitted to this office ~ithin three days of. ~nalysls
COUNTY OF l_x ERN
· .' Environmental Health Services Department
2700 '~VI" Stre~ Sail 300 . "
Bakersfield, CA 93301. .
~'1. A copy of this permit has been provided.to the Kern County Firs Department.
Permittee must notify the Kern County Environmental Health Departmen~ at
(805) 8~1-~3~ two wo~kln~ days p~io~ to tank (~emoval) o~
filling) to arrange for required inspections(s) .... .~'~".~.~ ¢?~:::' ' "
2. .. Permit~ee must obtain a City ~ire Department po~mit prior ~o'
closure action. " .. ',: -:-'.-' '..
3. .Tank closure activities must 'be per Kern County ~nvlronmental Health
Department and Fire Department approved methods as described in Handbook
~UT-30... : .......... · ..................... , .................. : ............. ....
PERMIT
FOR
PERMANENT
~LOSURE
· ..- .~?;-:.ang deviation .from .sample locations and numberS'?'or'}:.~nstituents.:tO'~.be
...--..-.. &~.~ sampled for which are 'described below and ~n HandbOok ~UT-~0 must receive
.... ..... prior approval by 'the'Envir°nme~ta/ Health Department]::L':}~-?:~-'t~:.~?~.,:'-..:' -~*-:.',~
.'~ ~-.?:~.'.'~." ' :a..',.~.,:..:.(Tank size 1,000 ~allons or."~leSS) - a mi~imum'of '~tw0 samples
.. ~'~. ~be [~'retrieved 4j. beneath ::~.~Center.., .. of "..depths
~.~ ,;-7~I-f-a~ m~,those.ttst~ i'-6-A=~r~-i-t
'-~6 Soti piping ,~anea
.... -~ ..... ~':a mintm~ of 'two samples 'must 'retrieved at ·depths approxim~tel~-two
..... '-~ ?-fee~ and six fee~ for every 15 linear fee~ of pipe ~run :and also near the
to/uene, xylene, and total petroleum hydrocarbons.~i.:-:' .,:.- --
8. Copies of trahspO~tat~on.:man~feSts must be aubmatted %to the':Kern""CoUn~y
..(' ',"~'[, '::"?,~Environmental Health, Department ~tthtn five days ~o'f .,w~ste disposal
~. : :'All 'applicable state 'laws' for hazardous waste a~aP°sal,'".t=anSP0~tat'~';
or t=eatment must be adhered to. The Kern County. Environmental Health
Department. must be notified before .~ovJng and/or "disposing 'of .any
:-' 10. ,.x:,:Per~ittee is responsible 'fo= making sure that "tank disposition' tracking
-.. reco=d"~Assued wt~h this permit is properly fille~ out and returned within
. '.'?.::'-Advise this office 0f 'the' ti~e"~nd ~ate of ~he proposed sampling W~h
12. Results must be submitted to this office within three days 'of analysis
ACCEPTED BY: ~ . DA
DS:
~a~
2700 M Street HEALTH OFFICER
Bakersfield, California ENVIRONMENTAL HEALTH DIVISION Leon M Hebertson, M.D.
Mailing Address: DIRECTOR OF ENVIRONMENTAL HEALTH
1415 Truxtun Avenue Vernon S. Reichard
Bakersfield, California 93301
(805) 861-3636
June 5, 1989
Smith International
P. O. Box 10809
Bakersfield, California 93304
CLOSURE OF 1 UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK LOCATED
AT 1207 34TH STREET IN THE CITY OF BAKERSFIELD, CALIFORNIA.
PERMIT # A925-06/060037
This is to advise you that this Department has reviewed the pro3ect
results for the preliminary assessment associated with the closure
of the tank noted above.
Based upon the sample results submitted, this Department is
satisfied that the assessment is complete and no significant soil
contamination has resulted from discharges from the sub3ect tank.
Thank-~E-q~o~.~your cooperation in this matter.
DAN STA~/~R~/.S., HAZARDOUS MATERIALS SPECIALIST
cc: G.R.I.
DISTRICT OFFICES
Delano · Lamont · L ;abella · Mojave · Rldgecrest · Shafter · Taft
..// "" ~ 5400 ALDI~IN CT.
,- groundwater resources inc. BAKERSFIELD, CALIFORNIA 9331.3
· General Engineering Contractor
Class A/Haz License No. 520768
Hay 16, 1989
Mr. Dan Starkey
Kern ~ounty Environmental
Health Services Department
2700'"M" Street, Suite.300
Bakersfield, CA 93301
............................ . ............................................................................ ~ ..
Re: Smith International
Permit #A925-06
Dear Mr. Starkey,
Enclosed please find a copy of the soil sample results, chain of
custody, manifest for the rinsate, and tracking sheets for the
abandonment of a 1,000 gallon gasoline tank on May 8, 1989
located at Smith International, 1207 34th Street, Bakersfield,
California. The tank was removed under Kern County Health
Department Permit #A925-06 and Bakersfield Fire Department
approval.
If you have any questions or require any further information,
please feel free to call 835-7700.
Very truly yours,
Y .
Pro3ect Oeologist
TCR:rl
Enclosure.
cc: Bob Ward
MAILING ADDRESS: P.O. BOX 9383, BAKERSFIELD, CA 93'389 (805) 835-7700
LOS~NGELES (213) 724-314-7
~oo r~o,~o, s~,o.i KERN COUNTY I IEALTH DI:PAm'MEN r IIEAUH.OFFICER
Bakerafleld, Cnlll~mla 93305 ~ Leon M Ilebell~, M.D.
Telephone {805) 861-3636 .... ENVIRONME~tlAL IlEAL;II UIVlSION
· ~~ .~~~ DIRECTOR OF ENVIRONMENTAL HEALTH
'~" /~~X~~~x Vernon S. Relcha~d
· Factll[y Name '... Kern County Permit ~
· * UNDERGROUND TANK IJISposITION TRACKING RECORD * *
'This ~orm Is to be returned to the Kern Gounty {[~ulth D~pnrtment within
.~. ~nys of neeeptane~ of tm~k(8) by disposal or re~yclln8 f~cl{lty,
............. ~m!d~r ~pf__ .the ~erm! t wi th _.numlmr noted, above _Is. uesponsibl~..~OU_Jj}~gF!.n~ "
thnt this form ts comp{oted nnd r, turned, .
Section ~ - T~ ~e filled out ~ tank removal contractor:
DaCe Tauks Removed~/~., / '. ~/~ No..: o~ Tanks
~ec~ton 2 - To be ~llled DUC ~ contractor "decon~amlna~lnff tank(s):
Address PhOlle t
_ Zip
Au~hortzed representative o~ contractor certifies by s/gnlug below Chat
tank(s) have been (lecoutnmJJmLed lJ] accorihillce wJ[.]l Kern Coui]Ly Iloulth
Uepur~ requi r~~
DaLe Tuuks ~ No, or Tanks
(Author/zed Representative)
· * * ~iAILING INSTRUCTIONS: Fold In Ira If and staple.
(Form #11~I~IP-~50 )
DiS]mcr OFFICES
' ~'". J,METAL } - .o. 30962
k,,,.. ./ RECYCLING, INC.j/ :l) TANK DISPOSAL FORM
2202 South Milliken Avenue ~, ~ C,, ~. I ~ ~'" :.Date: .
Ontario, CA 91761
(714) 947-2888 ~,( 1. ?'' '~0"~°" Job it
RO.# ....... ."'~
DESTiNATiON: 'A.M.R._..._ 2202 S. Milliken ...._Av~,,_..._,ontsrie. CA 91761
~ Se~ices Rendered : ::,: -: ~st
' - -P'~.-'"';'. C ::: .:~; .
Disposal ~ , :: ;= :....~ ,,:- ~ ;: .~,: :~ .~ :; T~ REC~VED ·
. ; ".~ ~:~, I~. ,. '-: ..........
O sposal Fee with ~i~ :,--:~? ' ~
Fi~rglass Tank Disposal ~ ~r Tank ~ ~ 1~. 12 lt.
..... ?, -~ ;.= ..: ~ ' 1~,61t. ~ D ,61~.. .,...
" ~-- .t- *) .... '
8obtail
Dispo~l
FH
~~ ~,. ~ 4~ ~ D Z421'"
TOTAL CHARGES .. $ ~ 7~
8~ D D 3.~
All fees incurred are per load unless specified. 1~ D D '4~ ,.
Terms are net 30 days from ~ate of invoice. 12~ D ~ 4.~
Contractor's signature represents acceptance .
of terms for payment, and confirms that tank NO. OF TANKS . TOTAL N~ ~NS
removal complies wit~ State laws. /'
,"F..~ FIBERG~SS
CONT~OR'S S~G~/URE ,,:..: ... ............. -~,,
CERTIFICATE OF TANK DISPO~L I DE~RU~ION
-- ~.,~,~ ~o c~,~.~.~c~,. ~.~ ~cc~.c~ o~ ~.~ ~.~ ~ ~.~c,~,~ ~ov~. ~ ~,~ ~.~c,~,~
AUTHORIZED RER ..... DATE : '.",:..
CONTRA~OR COPY ' ':"
.... . ,.:.:'-
~ ' ' " ' '.'7-'::
........ __~..;.. .......................... - ....... 7'--" : '
Form ApproVedprint type.gMs No. 2050--0039 (Expires g-3Oa~ / Toxic Subatlncea Control Divi=.
~.... 'o, ~Form do.,o.o. ,~ ... o. ~'2..,,~. ,~..,,,.~. Ins~cflons on t ack s.~,.~..,o, ~,,,or~
~ '~NIFORM U*~ARDOUS~ Generlt~'e US EPA ID ~. __ Manifeat ~ 2. Page 1 ~ IMor~tlon ~ the ihlded areal
o,,
4' ~ State ~leet D~u~nt N~
3. Generato~'~ Name and Mailing Address
O 5. ~ansp~,e, , Ce.puny Name 8. US EPA ~ Number C. Stile Tr.~.'. ~ ~ ~ ~
~~ 7. ~ransp~et 2 ~ompany Name 8. ~S EPA ID Number E. State ~rlnlp~e~l~
~ , 9. Designs/ed Ficilily Nsm~ and ~ile~dree~ ~ ~ ~ 10. US EPA ID Number G. ~llle Ficili~'l ID , :
~ Fac~'~e -....
~ ~/gl 5~~ ~ ~~~'17~7t¢6~] 7~7-~¢/
~ 12. ~l~nera /13. To/=I 14, L
.~ 1 ~. US DOT Deacription (Including P~op~ Shipping Nlme, ~zard Claa~, ~ ~ Number) No. Type Quanti~ WlUn~lVol W~lll
...... ~ .... N-- . _
E =b. , / State
R , ...........-- ~-2::,/.. :.'
o I ! I I ~ II
R c. ~ato.:
.: ,.-,.:.;',~:...-:~;.:::.:. '-.. - '_,,.
" ~A/~ .... - ·
I I I I I I I ' ~:~ '::".
d. :.~ '.' Stile
. ~ ~A/~ ,~. ~:-,..-
~/ ~~' ~-/ ~ ~ I I I I I
J. ~dit~al Oea~ipt~a f~ Mattel& Liste~ ~ ~ ~ ~e f~ Waetel ~ ~ve . -
h; k ' '"'? '?'""
~ ~ ~ ~ ~ ..~,-~ ., ...~?.. .,.,...,:~.,?..
' "~'; [ ' .:Z ::s ,-.'"
tS. Special ~ndling Inslraclioaa and Additional InI~lioa
8 .
/. hxt - ,.
1~.
GENERATOR'S CERTIFICATION: I hereby d~llre thai the c~t~t~ ~ thil cona~nment are ~IN and acc~ately de~dD~ a~ve by pro~er shipping name
and are classilied, packed, ma~ed, and label~, and ~e in ~11 re~a ~ proper c~ition lot tranap~ by highway accord~g to ~pp~cable ~temational
national government r~ulatio~a.
If I am a large quant~y generator, I ce~i~ that I have a program ~ place to reduce the volume and toxlci~ of waste generated lo t~ degree I have dele~ed
~ to be economically practicable and that I have selected the practicable meth~ of treatment, etorage, o~ diapo~l cu~tly availab~ to me whic~ minimizes the
present and future threat to human healt~ and the environment; ~, il I am a small quantity generator, I have made a g~d leith elf~ to minimize my
generation and select the beat waste managemenl melh~ t~at ie avai~ble to me and that I cae a~d.
T 17. Transpolar 1 Acknowledgement gl Receipt of Material~ ~
-' Z R
A Printed/Typed Name ~ / / __ ~ ~gnat~ · ~ /~ ~ / M~th Day Year
~ 18. ~ransp~er 2 Acknowledgement gl Receipl gl Maleriall .
~ Printed/Typed Name I ~gnalure M~t~ Day Year
I
E
~9. Discrepancy Indicat~n ~ace ..
~ ~ ~i'fo~ ~ ~n~n~ ~ ~e r~~ lot manifost do~mentation dates requi~
' ~ P d/Typ Name ~g~t M~I~ Day Year
(~/~)'""~:..." Do Nor ~low ~i5 Line ~ife: TSDF SENDS IS COPY TO ~HS ~ITHIN 30
~22
EPA 87~
(Rev. ~86) ~revious editions are obsolete. To: P.O. ~x 3~, ~mmento, ~ ~58t2
[ COUNTY KERN ' '
OP UNDERGROUND HAZARDOUS ~ '
-' FACILITY NAME/ADDRESS: OWNER(S ) N~E/ADDRESS:
· . ... . .., ,. .?~...
POST ON
e e i · · lee · · · e ese e Ieee see · · · e e e e · · t · · · · I · e · · i · e e I I e..I e i i e e e e e'.:,', '
~:. ~" ' .
1. A copy of this permit has been provided to th~ Kern 0runty Fi're[Department.
Per~ittee ~ust notify ~he Kern 0runty Environaental
(80fi) 861-3636 two ~or~lng da~s":prtor to tan~, (removal) or inertlng"and
2. Perml~ee ~us~ o~taln'~ Ol~y':Flre'Departmen~ Per~it'~rior'"'['t0"initiatlfig
3. Tank closure activities must be per Kern-~ County Environmental 'Health
.... Depar~men~ and Fire Department approved 'methods 'as described =in Handbook
~UT-30. '
.
BAKERSFIELD FIRE DEPARTMENT
5/~/~ 'BUREAU OF FIRE PREVENTION
Dm, ~' PERMIT Permit No.
granted to:
/ Na~ of ~ny
to. ~splay, store, install, u~,;'o~rate, ~11 or handle ~terials or Pr~ess involving or creating con-
diti~s deemed hazar~us to life or pro~r~ as follows:
t~rllO~¢l#~l J' J' EGLIN, lEG, CMEM. I~GI.
· ' 4100 PIERCE RD., BAKERSFIELD, CALIFORNIA 93308 PHONE 327-491 I
Put,cable
(SO~L) ·
~z~und~ater Resource ~ndust~ie~ Da~e
5610 District Blvd. Report: ll-May-89
Bakersfield, CA 93313
'Attention:
~ab No.: 3459-1 .
~mple Des¢.: ~2019
2'~ 'Below'Cent, er Of T~I(-GS';2-5/08/89
DATE SAMPEE DATE fx~LE DATE ANALYSIS
08-May-Sg 08-May-89 ll-MaM-89
~eporting Analysis Re~ortin~
Constituent Units Results Level
Ben~ene ug/g None Detected O. 02
Toluene u~/g None De%ected O. 02
Ethyl Benzene u~/g None Detected 0.02
p-Y~le~e ug/g None Detected O. 02
m-Xylene u~/g None Detected 0.02
o-Xylen6 ug/g None Detected O. 02
Total Pet.
H~drocarBon~ u~/g None De~ected $. O0
TEST METHOD: TPH for gasoline by D.O.H.$. L.U.F.T. method. ..... Individual cor,-~ti~ents by EPA rr~thod 8020.
Dry Mat~er ~asis
Co~ents:
C~alifornia D.O.H.S. ¢.~r%. ~102
J, J. EGLIN, II~,G. CHEM. ENGII.
· ~E~E~ ' ~ 41'00 PIERCE RD., ~KE~FI~D, CALIFORNIA 933~ PHONE 327-4911
~'geable ~tics
A~nt~on:
~nzene ~/g ~ ~~ O. 02
Tolu~e ~/g ~ne ~~ O. 02
o-~lene ~/g N~ ~~ O. 02
To~l Pe~.
TEST METHOD: TFH for ~asoline ~ D.O.H.S.L.U.F,T. ~%hod. · ~'- [n~ividual constituents by ~A ~thcxl 8020.
'D~ ~t~r ~is
~n~:
California D.O.H.S. Cert. ~102 -.
,,OOFIow.,S,,ee, M~.Y 1 0 ~N-C'-~UNTY H-DALTH:D[!PARTMEN, HEALT. OFaCEr~
Bakersfield, Calllomls 93305 Leon M Hebe~son, M.D.
* * UNDERGROUND TANK D'ISPOSITION TRACKING RECORD
' I ' ' -~ '. [:This form Is to be returned .:to the Kern County llealth D~partment within i4
~-~.¢.-::.~_Lholder__o~he~r~l.t ~lth~_nu~bee_noted above 1~ ~e~pon~lble'
'- ................... -' ' 2 Zip ~7 7~¢ "-~ .......
Section 2 - To be filled out ~ contractor "decontamlnatln~ tank(s):
Tank "DecontamJnat/on" Contractor ~ '~
Address Phone ~ '.
_ gtp
~utho~lzed ~p~e~entatl~e o~ 'con~ractor certifies bg ~lgnln[ below' that
tank(s} have been decontaminated In accordance with Kern County lieu/th
Depar tme~ requlremen~ . ~ l
{guthorlzeO Repre~entatlvo ~
* * * ~ILINO INSTRUUTIONS: Fold In hnlf und
(Form #II,IMP-150)
DISTRICT OFFICES
~ ~E~T. ~E~FIE~. ~ 93305
180SI ~1-3838
HAZ~DOUS 9UB$T~CE$ 9TORAGE.
~OJE~ CO~A~ ]PHONE . IS~/T/R (R~ ~TI~S ~LY)
Bob Dill ~ I ~'
,~e~. 834-6464
Smith Internati6nal 1207 34th street Jewett Avenue
Smith International P.O. Box 10809, Bakersfield (805)83'4- 6464
Groundwater Resources, Inc. I 5400 Aldrin Court, Bkfd ~ (805)835- 770~
5-8-89 I520768 I 0793569 I State Fund
Groundwater Resources, Inc. 5400 Aldrin Ct., Bkfd. (805)835- 7700
0793569 State Fund (805)834- 8300
SMC Labo~ato~ P.O. Box 80835, BA~d. (805)393- 3597
:H~I~L CON~$ITI~ Or ~l~ ~R~
.AT~ TO rACX'-ZTY PROVZD~O 8V IoEPT~ TO GRO~A~ATZR ,
~z California Water Servicec I 160'
-~ 650' I River Sand
. 'Z. 988 Report on Water Conditions., Kern County Water Agency
2 ~' BTX&E
GRI will decontaminate: 'tanks - rinsate hauled under manifest to Gibson
Refinery bv Oualitv V~]lum in
Tanks hauled as non-hazardous to A~ in Ontario
No major piping present'
' ' PL~E ~TO~ I~TT~ R~ Off R~ SIDE Of ~S ~ BE~RB S~I~TNO ~LTCATTON
1207 34TH STREET
s.Op
UNDERGROUND STORAGE TANK
46".x 12'
.
environmental/geotechni cai services
,r.jec, #.i,.r: ' II pLOT PLAN
ERN COUNTY HEALTH DEPARTMENt1~
Division of Env~onmental Health ,~- 2/- ~ ¢ Time:
SERVICE AND COMPLAINT FORM Date
~[~ Service Request [] Complaint CT No.~__.~__ ........ Assigned to: ...............................
,o~,o~.__/_~.~:.-._~..~.~~_,~ ...................................
Directions
Pro0erty Owner Address Phone
RESULTS OF ~ '
,.v,s~,~,o..~-2/- ~
Complainant notified
of results :lnvestl~ted by ~ate.
KCH~ 580 2760 372-EH (R.[[-80)
'KERN OOUNTY H~ALTH DEPARTMEN ., Division of Environmental Health
/~ 7 ~ ~ ~ ...........
Property Owner Address Phone
RESULTS OF
INVESTIGATION ...............................................................................................................................
Complainant notified
of results Investigated I~y ........................ ' Date ................................
KCHD 580 2760 372-EH (R.11-80)
'. '.' .::-:-....,.-,-..~t . ~i,l~ ,, . . · ., ; ,~:-:,,.,..,-.,,-.~., :~ERN COUNTY HE~LTH DEPARTMENT~':'-:t
""':' ~' .... ' '""~ ' '~. ' ". .... ~ ..... :..~'~::,:-".. .D~ws~on, of Envffonmental Health ~ ~... ~.~ ' ~ .
;':":" :':"""? ;: :~:{"~ SERVICE'~;AND. COMP~INT..FORM.,;;;'~:.~;;~?,,'' '"' "';:: :";;;' :':~' ' Date ~' ~/--~ ' ~ '
.. , ...-: .? ~ .....,. ,-..,, :~ '. . .';
- ~ ty '
.: ':" ;,./::,~. '...??.:: ;' Il ..... . ,;~ :., .,~ , ,.- .... : --- , ' '
~operty O~er .... ' ? ' ' ' ~ .... '
~,. - ;;~ , i; . - .........
. RESULTS' OF ' ~' · ' '
-:" ... ' ~~ '~. i-- )TS'.- .- .... ; ..... - --"HT:'L ......... ~-~~--~ -
'i~ . -
~OHO 580 27~0 ~72-~H
:...: ~--.,...~: ......
""'" .... """~' '" SERVICE AND ' ~ ,",,?~'-,, '..'.. · D~v~s~on of Environmental H . .:'.'.: .
.' .' ~':.;~:'.:.-.~:'~ ' ... ~, COMpLAINT:~FORM,:~:~.~??:,~:~ ' . :~.. :.. . . . ealth ' .... :,-~: ; . ~ . _ ~
.. - . T ..:.~ ' ' .~ ~ ~ ~. . ' ' '' /~ /~ -- /~ -- '/ ,
...... ~.,, .... ~..., .,.:, -..,.: ...,. ~~~~ ~ :' _ ,~ ..
' .~.~' Dlrectlonl
' : :..-' '. - ~ ,- ~4~, ~'~-.~."'.:..~;' ..' '~. ~-z'~. - · ~ ' . - -~ . .-
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'. ." · .' :- ' = ' -" , , ~--~-7 . , . ' - - Ad,reis ". ' ' .' ' ' '..." ~: ·
' ' ' ":' ' '~l R .- .~'¥ - .~ ............. _ ...... · ' ~one ~" ~. · ·
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..... :.?
:':: RESULTS 0F ~ ...... ~':"-" "':~ ~' ....... ,,~. ' Take, ~y ' i' ' ..
INVESTIGA I.ON~ · ~,,
~ - ',?~:~: ~ ' , .., .._ . ~ '=".
......... S ~ .... ~..
Complainant notlfle~:~ ' . ;~ ,..
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