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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />k##a#tRriaW#\r#rittikrrkttiti4#r\rtrt#!ti#rk###\##rrrl►►###itittr##rtt#fkrrt#rkif#s►##skrlit##rtt#its##### <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. TREkY SrTE' <br />FACILITY NAME:rE' r 1_0651 it t jfN( 4�, nfpoT ;S6m LAQAir1 <br />FACILITY ADDRESS: 25-7nn (tt R t5 MA M ?aQAID <br />�I <br />TANK ID J139-t��5(2c7 TANK SIZE:�ZcriPREVIOUS TANK CONTENTS: SEL v <br />rrar##rtW W##lilt;;W#ttW#i#ti##i#►#f\itkrti\''##\Wiir\�t\#rkWWWFWii###►►t\\#tiW►►ttWrW\lFrt►►ir#\�itikrtiiWWW## <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: CAtz -ZAA_ <br />Address: A040 Pd;4Zo6- 2na/� City: VAe-4vti L& Zip: 9.5687-669 <br />Phone d:( o 4) H 4 6— 719 6 Date Tank Removed:, <br />•sarirrrr■ssklkarsrriska;;isr#!►rsrrr#r;rrrirrrrrr►r#es■r\rrr►ilr♦•rs\rk#rrr#rrr►►rr►;#rrs#srrwla«lrrrirr#W <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Ems- <br />Address: <br />Phone q: ( 5i O."`a zj&r <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 />sftrlrsrrfrfr►l#ssfrfrrs■strsrf►s#\l►st►\s►t\lsrs#rrr►\stsi.:rst#;trsfs►sl►#s►►\!#f#fr\ssfr#ssssgsserrrir# <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 575- PA R P, R D r>~D City: R t C-lA at,200 Zip: Ql t Q 0/ <br />Phone p: ( .5t ri ) 0, S- — 1 3 11'22 <br />Date Tank Received: <br />Name: Title: Signature: Date <br />rs#■irrrri#s►r►irrrrrrrs#W#rrrrrrr►rt\#r#rs;lstt■rs►\r##srssrsrsW;srrrsststrr;rrtrrrrrssrr#rss►s;rrrisrr■ <br />EH 23 046 (Revised 9/11/96) Page 10 <br />