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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANX DISPOSITION TRACKING RECORD <br />iY\f/##trttMW##!i*i*#RRiiktiif/fiRlitiRtlt#i#itilt##ttttlkii*iiti\itk#rikff*iit!#r/rttlkiifi#*\flktiirtWW##Wf <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 CmF <br />FACILITY ADDRESS: <br />kT7p <br />TANK ID #39 -4icT 5<2_% TANK SIZE: 1 <br />4�REVIOUS TANK CONTENTS: Ute., (ea,,je�j �yl <br />rr+/#rrr#rlrrrlrlr/wririlrlfktririrrrr*\■r;RrrirrlirrrrriliRis//rrrairsir;rsr*rWi\isirirsr\#\+irii*liirrirr <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: a040 PJ94[iof-)�s" IZ0a/-'I City: VA<_AylLLF Zip: 9.56e7-6694 <br />Phone q: ( O 4) y q 6. -- 77 9 6 Date Tank Removed: <br />\\i//i#ittssrlRit►ir•tM#►*r/♦•iii•iiiMlrri\R\Rrit\k\i*ir♦iWift/itirri\llirrii!lMMs!!i;♦ilifi**Yr**rrWWiiiWi <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: -- s ��+o City: MRQi i1J'F-:Z Zip: X14 <br />Phone #: (5"/ O) Z 2 fh --- 73 33 <br />Authorized representative of contractor certifying through signature below that the tank has been deconrarainared in an approved <br />manner as required by Cal EPA. <br />Name: Title: Signature: Date <br />**#fktit\iktir##*t!■tt#ti#ki*ii##t!i!k#t#ff##irr**fitli#**ir.:likRtltklki#fsiitk#f!klit###►#*fiRRi■**t*#Ri\! <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: EG T y� r_Z 1 I4'SO n) <br />Address: _?_55 PR p, P, R o4t> City: RICA Zip: `T+l 4 0l <br />Phone R: ( ,dT it) ) a - :x, — 13`13 <br />Date Tank Received: <br />Name: Title: Signature: Date <br />� Riti/Wit*i!!tt!/i\R/itlR►\\tWli•rrititi\*if•s\r■tilrRi#!t►i\;*i*i\rklitR\ii\it;titt♦;;;#►itisrii♦tr♦iYfii <br />EH 23 046 (Revised 9/11/96) Page 10 <br />