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Mar . 9 , 2006 2:45PM Piaht EW roomental 832-5152 Vo - 3586 2 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> w##WrRR;RriNNkki#;saais}figrtNFR##waaR#Frrtfi###;aRafirtgrtq#;#;##i#gkRa#rtrtrtrtiMar##iWF#rrasr#}«a#i}tai##FYar}q##ii <br /> SECTION I- Public Health Services Frivironmeolal Health Division Tank Tracking Sheet shall accompany escli tank affixed with <br /> its site identification number. The Tads Tracking Sheet is to be returned to Public Health Services Environmental llealth Division <br /> within 30 days of acceptance of the rank by the disposal or recycling facility, The pernilt bolder is responsible for ensuring that <br /> this forst is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS:- rQ•� .1 ;—.7C.y - <br /> TANK 1D N39- S78 TANK SIZE:,` PREVIOUS TANK CON`jFNTS:l[/ !tI I/j) <br /> N##}itaa}}}wYRk#}f#}}}##}fr#raRR4r#ww}IRaaaF}##a###}#}}M}#Riar#NaaaRRR4}N}a;;ar}a##}}aaaaiaa}a#wRY##}#}}Nrii <br /> SECTION 2-To be filled out hy tank removal co/nrtr�actor: <br /> n f�Tank Removal Contractor: W/ rn!7/ <br /> ..— /•aa fe'S <br /> Addressl c— City; 1p7Li — <br /> .— <br /> Phone `j }-422 Date Tank Removed; '/�a <br /> k#4ww}#}###Ria}fi##ggrtW#R######}rt#rtrt#si#Yi#NWWNRs#Nfifi#WWW;s##M}RRRi«rtW#k#aiwR###}RR#i#iq♦R}•rt#4aa#Nrt#iR#Ri;rt <br /> SECTION 3-To be filled oat by contractor"decontaminating tank": <br /> Talc Decontamination Contractor: �C'1 ' r i //)flf r(o!(:t' �./!7 • L—� <br /> Address: /(—I�� 5�-�. I/�C/,- City: <br /> Phone rp: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as rcquircd by Cal EPA. <br /> Name: T�r'� �BWNS Title: PIzoTEC.( &R, Signature:-9. <br /> +4Yrraarr4Firi.4wNFrr;tarrrr}}F4#a#rrr#wrt##}#ww#VY#RRR#RNrgRRa«#gNRrirar}}}qR#ksRrrrt#MsrR##;##}r##«rragW# <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: <br /> // lJ ,..,��T9 �,/• <br /> Address:_)�C,rl��7CJ/,,/�,,�q) • �f] ;t7WQeo ..`Cdy:�. _Zip: <br /> Phone/:�'Lk4_�! J - <br /> — —. —.— <br /> Datt Tank Received: D 7 <br /> Namr.• Titic:�,� Signature: Date����...— <br /> i}#grains}iiNrRR#fi##qr;W#.YR;+wr}}Nq}raRr}#N+##asa4wqq##r;#RFrw;}#sirtr#k##irrrr#rtik+r4r#w#RRRgWirsrrq}s;aiR <br /> EH 23 046 (Revised Og/13/99) Page 10 <br /> I <br /> 3 <br />