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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:_ ; Ntti N P., R� <br /> TANK ID#39 - TANK SIZE: 1 ��Y5 PREVIOUS TANK CONTENTS:: U n) e_& ,zl <br /> SECTION 2 -To be filled out by tank removal contractor <br /> Tank Removal Contractor: S q�k m 0— <br /> Address: 4• x Q 21; City: L(3;s I C_ys Zip: 1 3 Q <br /> Phone#: O �- i �7 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: X�s <br /> Address: P,O �k �� City:L,ps (IjAN M Zip: 3 6 <br /> Phone#: <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 L s� LO,45� i l5 b M L' yi� <br /> Address: O O /q. i`J�� N l�\ Ciry: 1 '�1 � Zip- - Z <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />