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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />♦i►fifts*rtrittr*#it#*#tt►tr«fttrtti#rs■iii#isi#igtiitkfr#ifk/tt#firtfiRk#*frttk#«««r►#»iitt»«tt##i►►ttr«t#*fit#V/ <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. -FFWY SffE <br />FACILITY ADDRESS: <br />TANK ID #39-x(7157Anr 7 TANK SIZE: 12, CM3 c�_�PREVIOUS TANK CONTENTS: LA eI <br />i►»t/YV/►ii►4445iiiiVMti4iiiRitititi►i►t►►�f►►►►►tit►►�►►t►►►►►/►/►►►►t►►4►M►fRVVVV►►►YMitit►ti4!!!/l1Y4444 Vi <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: cAt- X NG <br />Address: aO1-f0 A548onY ROao City:yac.Ayzue Zip: 9.5687-6694 <br />Phone p: ( o ) H 14 6 — 719 6 Date Tank Removed: <br />t«trtp«►tk#Rt■Rtttftitittiiitrif■iiRRV■Viiitttii►ti*►«►tRiifkirtr4RrtR4titt Vtfi«ifiM►ttiiiitRtR«trit►►R/tiiV VY <br />SECTION 3 - To be filled out by contractor "decontaminating tank": ^ Q <br />Tank Decontamination Contractor: P-4e,t /�LYvt t� / y r f j ► }- �A �i� B �S <br />Address �T Ciry f !AldT'ip =r - <br />Phone N: (-4i <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 />Title: Signature: Date <br />■ass►rtrr*rts►s►##rtrtR#Ri»►»»«ss►iitfirt4*#*#r*►r►►itRrrt►tis►►..�►ertrt►tt►►»fins«ttrfa►*«►r«**#rssttsisiitii►rti <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: ECT <br />Address: Z 57S PAP, R R O A t> City: R t C -A aan.lo Zip: qtf 4Ol <br />Phone R: (."St r) a s `i -5 <br />Date Tank Received: <br />Title: Signature: Date <br />it/pp«t«sts«/itiiit►r«tti4Rt/«ttttttti«t►shit►■«»iit■t►titiNs►tfiftt«ittrf V44/ttlsitRs►«»titViiYVrV ltf <br />EH 23 046 (Revised 9/11/96) Page 10 <br />