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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICrS <br />Esti MONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACIONG 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 />F'ACM I r NAME: <br />FACILITY ADDRESS: W q fZA N_tj l N ,� Rd <br />TANK M #39 - TANK SIZE: t PREVIOUS TANK CONTENTS:sZ9 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: C-\ <br />Address: • Qx City: !-OS 1 q <br />- �AN � Zip: <br />Phone tf: (�),- j �7 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: {�)_L/��i <br />o <br />Address: City: <br />Las j,aN NS <br />Phone f#: (2-Q)01 .� - i , % <br />Authorized representative of contractor certifying through signature below that the tans: has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Title: <br />Signature: <br />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}J'� S� C-O�I.S�, V b M e,Mlr <br />Address: O O LX CityTv 12�c7 CA�,_ Z:p: <br />Phone /#: (�_) [�,�� - 2 3 --) f< <br />Date Tank Received: <br />Name: Title: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page i0 <br />Date <br />