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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSMON 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 />FACMTYILTA-YG <br />FACILITY ADDRESS: -7 `} Com; G RA NT -L t t,� fZ <br />TANK M#39 - TANK SIZE: O PREVIOUS TANK CONTENTS: N Le -q& <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: s M GL, i u e <br />Address: City: as, )�ANa Zip: <br />Phone ;t: (�Q9 )_­7�'4 - S `? D Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: �,, © c� b� City:% i`ll—, Zip= MATS <br />Phone /t: (`LCFj — I n <br />Authorized representative of contractor certifying through signature below that the tank has been deconraminated in an approved <br />manner as required by Cal EPA - <br />Name: Title: <br />Signature: <br />Date <br />�«:* ** »�a�s**** **�**�ss�*«***�.�#**.�***�**«*r*�►s*�**«****�rss:*,k,�*s***sr*�*�*.. * «*s* *�.�..*..mss,.***.*a.s�*�* * *:« <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 —P—� CQ4�- 01 <br />Address: I ('� � . W A L. 4 ll \ Ciry U tZ�O Zip: �j S <br />Phone /#: (��)(4,6`_=T( <br />Date Tank Received: <br />Name: <br />Title: <br />Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Dace <br />