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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />############################## <br />SECTION 1 - 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: 'Tito <br />FACILITY ADDRESS: <br />, ga 6- C <br />S +OC k-ke/') <br />TANK ID #39 - 4 JS336 / TANK SIZE: Id 6W LV' PREVIOUS TANK CONTENTS: ��✓�''� SAS �'iJ+� <br />####k###*###############k##k##kk#kk#######k##########k####k##*####*##k##################kkk######k**####kk# <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 3T C . 2 Tt r (� ��t City: S�odl- tcN Zip: 9 -5—� 1 S'kMQ <br />Phone #: ( 20 rl ) 4C S 7—(0 ( (0 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: , 6v <br />Address:7 SdO n�m ES Roue, City: �1� I I K Zip: 9,5'03 S <br />Phone #: ( �D ) `7 (f — <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: <br />Signature: <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: G V L <br />Address: a S s PFt r h 6((!d City: fiV Zip: 1 4 dQ <br />Phone #: (51('-) ) 31-3 S "- 13 e --f � <br />Date Tank Received: <br />Name: Title: Signature: <br />EH 23 046 (Revised 9/11/96) Page 10 <br />