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M <br />... <br />SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENMONIMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />o ..,I Y.... Y Y r. r.. Y.... Yr r Y.. Y r.. YY Y YYn.rr •!«Y........••r.Y.rlY«rr NYNYr..bNrYrurN•YY Yr,YrYN IrYIMYN <br />SECTION I • Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each Walk Mixed 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 or acceptance of the tank by the disposal or recycling facility. The permit bolder is responsible for ensuring that <br />Nis form is completed end returned. • D <br />FACILITY NAME: ^1 �--�� "` 'I- ' <br />FACILITY ADDRESS: !:.P •! Z <br />TANK ID N39 • % �1 TANK SIZE: 4y'00PREVIOUS TANK CONTENTS ,ua( v wllo <br />ur.YlYYgyurYrrY •. ♦r• Y r r«rwrH«««M Y • YYY Y YU N!««Nr.rlrrru«r««Yr MINlM • j.««Q♦rH• H.H««•«rr4•!«Hq Y <br />SECTION 2 • To be filled out by tank removal contractor: _ <br />Tank Removal Contractorrj5-> �lC�'Oi7ac'rtr3 65 \�- JQ <br />Address:l C`ri i�f <br />LA 1 �cT _ City:��� Zip: <br />Phone N: O C[-33 Date lank Removed: <br />YYr YrllrrYYI1Y rY1irYI... i1 YYY...... Yf YYYtYY.Y.YYYYrYYr ............... a............ Y.Y.... r. Y1 YYYYYY........ <br />SECTION 3 - To be filled out by contractor "decontat9inating tank": <br />Tank Decontamination Contractor. <br />Address: <br />Phone N'. <br />Zip. <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 />Name: Title Signature: Dare <br />•...Y...Y•.YY.Y.Y...........r........ <br />rYY.1Yrr.YYrrYlr.r..YYYrr YYYYrr.r.6r«rrrr..lrr.«Y.«Y«.rrYrr«rNHY...r <br />SECTION d - 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. F <br />p <br />Address: ��� \ �i� �- �t k t' City:�r �a uPn 17 Zip: 15696 <br />Phone t (.5-10%0 <br />pate Tank Receeived: <br />Nxme:IYI / e�if���� Title: <br />Date�� <br />r1••YrY•Yrrrr••r•rrrrrr•..Y«rrrr•rrYr•'r.Yrrrrr.rrr•rr•rYa YYYr.l.......rr!«Y•r.•..Yrr.. rr•rrrrr rrrrl Y rrrrr <br />EH 23 046 (Revised 08/13199) <br />Page 10 <br />