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12/22/2003 12:22 53066657AB NOR CAL CON PAGE 02 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ##4444ssssssit44Wlt4s>;•sasik4YY!!!!Ws••tl444tW4W!!##kkssssati4#W!Yl4Rtisalit!!4#W;;tisss>i4a4444!!4t•siits <br /> SECTION 1 -SIC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is complete( <br /> and returned. <br /> FACILITY NAME: �Y��i y 7 <br /> FACILITY ADDRESS: <br /> /J��C'4G �j/"FJf / � <br /> TANK ID#39- TANK SIZE: J �y R PREVIOUS TANK CONTENTS! 6 �,4 :1A <br /> st>sN>4rtW#klMssasstaiY,W4Y4 YsgassgsYi4iW4l4kttsatispaa;4WWMlMssapsai#lk4tsetspsY4tY4ltMspisi>44!#! <br /> SECTION 2-To be filled out <br /> /byy tannkr removal contractor: / <br /> Tank Removal Contractor: /.r(�iC�r1 f L64 e/K, C_r- dr <br /> Address: 3 , City: ldkt)Lwt ZiP:I..?2/L <br /> Phone#:( S,1i(� )�.,/.� --� 7 d Date Tank Removed: <br /> #itsissw4l4!!Ws>ta>a>ta;iiiwY!l44iatitsaa>iYl4#4klWWWWsstssatia44W;rytiataaaaartrt4!lttsis>sttst4#WWWwsW atiast <br /> SECTION 3-To be filled out by contractor"decontaminating lank": <br /> Tank Decontamination Contractor: /YI1 <br /> Address: City: Zip: <br /> Phone#:�) <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: Date <br /> W4WYYtssfstt>#Ott;4t#i;i>itWWl444Yts;ts»walY44444iitssassssiiW44WWWtts♦i4W4W#44tas>ss>s4W44444YWYaaatititM <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; t� <br /> Address: !aa/�'/C//�C .P�LLCity:,�����Zip: <br /> Phone#: <br /> Date Tank Received: <br /> e- Title: di'✓SA9 r6N Signature �✓J/ Datel/7�2-/IO <br /> tit>a44#WWWaiatiWW4W4#tttaaa44WWWWatat>ti4WWk Ytatititaa4W4WYatsi#4i#44WWRattitaNW#kR4WtWYsta44W#YYtiiYY#W <br /> EH 23 046 (Revised 3/15/02) Page 10 <br />