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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - 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 />FACILITYx,t <br />FACILITY ADDRESS: �� � Ca r%�NTL i N i1 A <br />I I <br />TANK ID #39 - TANK SIZE: % O ; O PREVIOUS TANK CONTENTS: `r --� <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Q �, S iL(\!s, L i N c� II -- c, ` <br />Address: _�J o�c e_5 Ciry: LSCS i�ANC} s zip: 131r3� <br />Phone #: (�Z 9_) `6" - i S --? n Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: S ] 17,ACi L1 N e - <br />Address: 9 O. City:LoAN-0-5 Zip: <br />Phone #: ( Z01 ) -,�' �b - \ n <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 />,fame _ Title: _= Signature- Date_ ' <br />_i <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: V,i Q . ST GO A ST C li M n! I <br />Lo <br />II'' <br />Address: D G l� W L fel U� Ciry:TO 2L0 c K Zip: qS�'p <br />Phone I#: (�.Q ) 6 b `�j `� 3 % <br />Date Tank Received: <br />Name: Title: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Date <br />