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I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> srrtr+rtwrtrtsrrt+rtrt+rtartssaasrar«w«rrrtw+r++rtw»wa++rtrrt»r+arrtrt++»r+rrwrw*r+rt++»++++++++»»»+rts+»»rt»rtr+++++r++»+++ <br /> SECTION 1- 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 returned 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. -y, <br /> FACILITTYNAME: -6 QT 'I�YJYi Lit!/-r�,I_rS`pe a�,�U,0 4/ <br /> FACILITY ADDRESSP✓l <br /> TANK 1D#39- TANK SIZE: PREVIOUS TANK CONTENTS:[[�nf1XJLtJ/IJ <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: W�Ig!l� T I,) rn n r)')ltArl <br /> Address: 70 /I ,�� • � City: %q 2C SV Zip: <br /> Phone#: (p 6 ) R IR 3-/q J�6{ Date Tank Removed: <br /> rtw+w+trt»t»++rtra»»+*r*r+»r*rtr*++rtwrt»w»t+r»+«srartrt+rtrt+srrt+srt++ta»«»wrtrtwa«rt««trt+»»»tt++t++++a+»rtw+»+++++++»++ <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: Nr 1$'// �y12 tJ1`(f/711 S�i SS C - <br /> Address: /��//�(�� U l l /AA� 9�. 4L-JW City: /fie Zip: 957_ <br /> Phone N: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> i <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> aata+rrrwrt+++arra+war++rsa++asr+++s+*+»tarta+awrtrtt+rtsrr++++asa++rtara++**++++r+a+++artrrt+ars»++»rw++»+wwt+r«+ <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting <br /> gtta_1nk annd/%oorr piping. <br /> FacilityName: 1k)e)T <br /> r <br /> Address: City: Zip: <br /> Phone k: (fir <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ++++rww+++++t»«r+»rt+++r++rt++rr+a++++ww++r++wra+r++«++++as+++++a+rwa++rrta»++rtarwrt+++r»+arrr+»r»+r+r++ra»++ <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> i <br />