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M <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />MAY 19 1999 <br />ENVIRONiME�N#�1'H�L NEALTh <br />SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: Sft�Jf4C I t iNG . BA PW10 QtTI fr <br />FACILITY ADDRESS: <br />10C CA <br />CA j S L15 �tx� <br />TANK ID #39 - TANK SIZE: 1000 W PREVIOUS TANK CONTENTS <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: ,)�\d AC, I LA/c— . (» 1i Koter) WTC' <br />ID <br />Address:- y ko CA kj2e4-+,f-- f City: SI UL 4G Zip: --9S Z —g%0 0 <br />Phone N: (fid OR ) Tbs ' : i I (.eDate Tank Removed: 3 — oR 9 Q 9 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: IkVANCx, C.(QOW-(tP %ec n vl Ies .Tam <br />Address: t "`T—f"t►7 City: I Zip: <br />&,eeil Q /f �QNfGII� g�S�v <br />Phone S-(7 T lS� <br />Authorize repr entative of contractor certifying through signature below that the tank has been dgcontaminated in an approved <br />manner as required by Cal EPA. ,� A t <br />Name: 9WWkf,,jgA Title: p✓S �/u/1 , Signature:�jt� Date y <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: 6, C. I <br />Address: °Z PA r r 31VA . City: le,GAhokol —L1 Zip: <br />Phone N: (SIU ) A 3 S —139-3 <br />Date Tank Received: 3- 2'� '" <br />Name: S- KLDONNELi, Tide: 0000 ,(Z Signature: <�: <qV"- Date 3- 2-5 - 19 <br />EH 23 046 (Revised 9/11/96) Page 10 <br />