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40G-1Cf-1777 e17•dk�� 1'1 rKUI'I U 14GJGJltI(d H.by <br /> SAN JOAQUi.. COUNTY PUBLIC <br /> gEALTH SERVICES <br /> ENV ONMWUL HEALMY DIVLSI.ON <br /> UNDERGROUND STORAGE TANK DLSPOSPTION TRACKING RECORD <br /> a�rutss t�4urr��,wyitst=+rsa a+n�r#,w�rw�r+�---re�ia�w�inea.�+s*r w��ieI.f�..ewuM w�e�+r,�w.M <br />>ECTION l - lic Health Services Emgm l Health Division Tank Tracking She~;shall accompany each tank aft,, d wish <br />,u sire identifr on tttimb The Tank Tracf6ng Shot is to be returned to Public Health Services EZvirv=cntsl Health Division <br /> vithin 30:days of acceptance of die tank by the disposal or rt--fd ng fleditY. The Permit holder is rano=-ble for cmuring char <br /> bis form is completed and maned. <br />-AGILITY N IME: <br />'Acmxry AqDRFs&5 <br />'ANK ID X39 WANK SIZE: % FREYIOUS T.�N;{CONTF—N-M: <br /> rtr�:rtrtrtr#re yiM+k+kt+wt�nYMtY#+FarWnarqs**+rfaa=+Strawn4sW4t#xr*aiY+Wkss�+tltfis*#i��n�==�T ,k,�rclA[ar%npe�rtkrM+Ws <br /> EMON Z - To be•filled ant by tank removal contractor: To (g`,00Tc72m <br /> I <br /> I <br /> anis Removal Eonrtactor. <br /> ddre,,s: I - <br /> i City: Zip: <br /> zone Dae Tack Removed: <br />[+ass#4cgtWss*+1 +fokk+tat�oraiwcy*srMf�imt�s�rM+ks��wquYWt�csa�yuM�ace.rttltwrrea.a.rsvc McwrWra.+:a rrnnri r.,ea�+ibY we+r�awi iMwM <br />:CYTON 3.- o be (riled out by contractor"decontamfbnating tank": L/�vDc 2 Sc�i4>�r�Tc T <br /> mk Der--ntaa <br /> II' on Cnntracmr: � <br />-:dress: �L?7 i'i �[,(/J� ' <br /> 2horized;rep 'lie-of coamac:cr=tifying d,U`ou#srg,tat= below that the tank has beta de-=atamiaated is an approved <br /> min77 <br /> e ed by Cai EPA. <br /> me:er as <br /> Tube: Signattzcc. Dale <br />�r�yaeac*s �e.4.scat+ewaot,aul+rkMsss�itrAessr��+�aupk�+a44rnbWe+s +w�wrrw tors <br /> CTION'4- be signed and dated by an authorized representative of tlFt treatment, =rage, ar disposal facmv <br /> iting task and/or piping. <br /> duty,Name: <br /> City: zip: l <br />-e Tanis Rewi v ed: <br /> Ttle: <br /> Signe: Date <br /> r+laas+err+a+I M+Ykss uarw arasarw�ex,a ,�yr+bessris-sss+n�assta <br /> . I 'rt==y�:�tst'aotarrr=yor�uM rlr::y r.Y.i.W ss<ai= <br /> 23 046 (Revised 10119/98) pagc Ip <br /> I <br />