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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility_ The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY ADDRESS: a 7 I ~ W G P-ANIt I N e <br /> TANK ID#39 - TANK SIZE: -J 0 PREVIOUS TANK CONTENTS: Z C)N e-4 ec� <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: kA C�,,KI q <br /> Address: O � (� City:L N as Zip: 13 6 <br /> Phone#: (�o9) -7fn,6 ` s 7 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: E3 5 C9 LA r <br /> Address: c) `7 b� City: o s PAN2j6 Zip: �12�1,S <br /> Phone#: (`L(j <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: Title: 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: W'e�� AS1 I ()A e <br /> Address: D b A,,L�4 i \ City7y&U,L K <br /> Date Tank Received: <br /> Name: _Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />