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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />u..... r..... 4«....... r. r«. r.........4 r i.4 H.M.........rrq.M4rr.libr. uM.r.f Y+aa..«..4l.i.r4f4liq.Y+r <br />SECTION 1. Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany cock tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be resumed to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permlt holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: ---�ICY3 <br />FACILITY ADDRESS? /'2 /2 /q r/ <br />TANK ID #39 • TANK SIZE: 4�% PREVIOUS TANK CONTENTS: <br />•O rlrr4l i.1//4!!4+/.rr M+r 4+1Y4Y ii4i i+Y Y+Y 4 H r i 44i Ni/H ri+/!!!4r il4i i i 4r++t44YMli! r++++liYiil44Yi41r14 r <br />SECTION 2 • To be filled out by tank removal contractor: <br />,,,�r <br />Tank Removal Contraclor a --Z <br />Address: �i 9 0 t City: Zip: 2w <br />Phone M: (00`77)_ctr1cf' q -Z 33 Date Tank <br />u.rl.orrrrlrr.«1.IH.r+♦4rA...frt#lr.rrr...r..r.K«..........a....rlr.rHgga+.....r/4...bMr«+.+.a.r. <br />SECTION 3 - To be filled out by contractor"decontan�1nating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone C <br />City: 7ip <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 />Title: Signature: Dare <br />.. r. r. r..... •....... r....... H................r«r. t • r4.rar iK...4... Y.Y tra4 r H.I...4..Y P rp grrHgl... •. <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. C <br />Address: 7-637 te-r— - City, >` p <br />re� 4 ?.l%J Zip: <br />Phone N: ('57r). Z,s �3g� <br />Date Tank <br />Title: Signature: Date <br />r. r r. rr.+r++r.. t» r+++r. o u I r r ... r+++r.'Y r«+a+r. r r++r rr. r.. r. u..+.+.. rr*..V1 .... <br />EH 23 046 (Revised 08113199) Page 10 <br />