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� u <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> YirttWrrtr}rlrk#rick}krt#!#r+i#lkrirrrtr»##rki»trrW«rtrtWWi#r##+»rtkriY»rrtW++#k»+rr#iii+}rrtrk##rtr+k}rt+rrt}i#»rt+W+rtW <br /> SECTION I- Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each*tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be retuned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME- /� r <br /> FACILITY ADDRESS: <br /> TANK ID#39- TANK SIZE: <br /> PREVIOUS TANK CONTENTS: <br /> +«s}w«rarsrsrkrr}ktiki}#rikrk•+srtW+rkkkr#+Wr++rtr+!}krrti+rrtrrrtrrt#rtks#rkrt«rls.kW+ik}krlrt++rtsrrirs»r«s«irtirrt <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> //�� <br /> Address:—M 19 �1� - , <br /> /� City: Zip; 95 <br /> Phone M: (W)-R3 - (/7'17(� <br /> Date Tank Removed: <br /> rlrtrrsrs»i»ss#k+ars»a}s+rWir«+r+rrrsrrr«rr«sWrirrirss}rks»irs»rr»r#rss»*s«rrrsssrls»rrtr•rr*rrr»sssrsrr+rrr» <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor:�j� <br /> Address:_7�7 <br /> � Phone#: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> manner as required by Cal EPA. approved <br /> I Name: Title: <br /> SignaNre: Date <br /> k»#rrt+rrrkr#+rt+r«+«rtrrtrrtr##rr+irtkkrW#+ri}•kkrrrrt+Wtrtrtrrtrki«+rrrtrtrtwrrrtr+r»rkkrrr++rtkWlr+}krikairrrr+Wrrrir+ <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, Stora e, or disposal <br /> accepting tank and/or piping, g posa! facility <br /> Facility Name: t <br /> Address: <br /> City:__Zip: <br /> Phone M: �---- <br /> Date Tank Received: <br /> Name: Title: <br /> Signature: Date_ <br /> w+}art+#l+rrlrt»rr}+»wrrrti»kWr#kr+r+r+irtr#rrtrti#»Wr#»r+r+r+r+rtr++++rrs+i+rsWrr+rrl+Wrti«s+rr+r+r»r»+rrHri# <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />