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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: r<ANTL i N c 12 II <br /> TANK ID#39 - TANK SIZE: PREVIOUS TANK CONTENTS:'�6_'_� e <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: S Z C„L i N !✓ II -- <br /> Address: y-� '�o�C Tj City: Las &N o-s Zip: '13 j�_S <br /> Phone#: (`' J 9) `M - S`71l Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: K S RA Li Jul I?_ <br /> Address:p O, \�Px City:LO 5 ANO-, Zip: <br /> Phone#: ( u),l ) -K <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: 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: W'e,sT C-o a-s-T E O M ty At <br /> Address: b O N �_xj>a L nl u 1 City:TO PL0 c k Zip: crS Fy <br /> Phone#: (x.09 ) 66_x,' 'J3 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />