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SAN JOAQUIN COUNTY PUBLIC MALTH SERVICES <br /> EA'VIRONMLN7AL EHALTE DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> _ ........................................................................................................... <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Shea shall accompany each tank affixed <br /> with its site identification number. The Tznk Tracking Sbat is to be rcr=ed 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. <br /> ITY <br /> FACILNAME: A q - A r T <br /> FACILITY ADDRESS: 3 1 3 3 W. A d A rT R oaa, 5 7 o c IS 7 0 ti <br /> TA.`K ID r39 - TAMC SIZE: 500 qy I PREVIOUS TANK CONTENTS: wast. 0 <br /> ........................................................................................................... <br /> SECTION 2 - To be filled out by tank removal co// racr. <br /> nto <br /> ' Tank Removal Contractor. A d V a 0 (t� V t 0 E n V I ro h M J N/c( 1 , :r N ( <br /> Address:-4005- W. Wi 150 h wq s/ -CITY: S O (K O h Zip: 9 S`.Z O <br /> Phone 4 6 7 ' 1006 Date -z=k Removed: <br /> ........................................................................................................... <br /> SECTION 3 - To be filled out by contnrror "decontaminating tank ": <br /> Tank Decontamination Contractor: A C Va q ( +(/ ('r o ),-N V i N o n K1 'N Y4 I t Z4 ( . <br /> Address: gOO4 A/. W1' 15ai W'qV City: 570 ( 00✓1 Zip: C?5A05 <br /> Phone96 7 - 1006 <br /> Authorized representative of contractor c:-:fying u'roug; simature bellow -at the tank has been drontz-..ia<ed in an approved <br /> manner as required by C:J EPA. <br /> Name: 10vin M ' K;0'(11 Tit'.-: tr. IWT G%101W) Sgranse: Rim 14r4'1 D;ucel-1S_96 <br /> ........................................................................................................... <br /> SECTION 4 - To be sited and dated by zn authorized rtpresentarive of the a-eatmcnt, storage, or disposal facility <br /> accepting tank and/or p;:`_'_E. <br /> FacilityNzme: WAST- CoaS !TF U;PM,ht <br /> Address: 5100 Taylor Cove City: Turl0CK Zip: g53S ) <br /> Date Tank R gcived: - <br /> Name: ✓ Title: �(Lt,L_ Signator . Dale �j-az�S ^ <br /> ............................ .......................................................................... <br /> Eli 23 046 (Revised 9111196) Page 10 <br />