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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> \rifri\rriiiif.ri\\tri\frlrii\/8#\lfiiiiiiiiiii\rff\i\ii#1\\\f\fYYYi#41\f!\fi��\iYiii\rariY.iY#i#aYii\tali\ii <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 urn <br /> d and reted. <br /> FACILITY NAME: A c1 — A r T <br /> FACILITY ADDRESS: 3 ) 3 3 W. Fl d A r T &44,t 5 / O C V o q <br /> T?u�11C ID n 9 - a 3 TANK SIZE: 3 t 00 0 q q PREVIOUS TANK CONTEN I S: c�I+S a <br /> Yrr#ri........i#.0...........ir\\i..........*..........Yii\ar.#tYrrYYi....... \lr.i\.....irrrriiYYi#fiiifirrr <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> n <br /> Tank Removal Contactor. ti 4yaN (,@d &.Po EF /1y; Y'0 h t jo7c I , X N C . <br /> Address:-4005- IV- WN-5611 Wg s/ city: S 1 o cK T O h Zip: 9 S`7.0 5 <br /> i <br /> Phone n: ( ;L0 ) u 6 7 - 100 6 Date Tank Removed: <br /> ...f.i......ri.f\.....lf f..Y\..f...........tri......\a..f.......f.r..0\r.r..............r.........irY.Yi.i <br /> SECTION 3 - To be filled out by contractor "decontaminating tank-": <br /> Tank Decontamination Contractor: A qya q C .1d (9.0 0 IC N vii N o n H1'N 14 1 T N e - <br /> Address: 4 0 0 � N• w i 156 h w'a V city: 510(14)61,1 zip: q6.105— <br /> Phone n: ( '�0 ) 'i6 7 - 1006 <br /> Authorized representative of contractor cerjfty g trough signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> ....Y...r ..........talc.r....rYY.r\l.Y.....**..Y......f......W..*....Y.r....i...YY..i <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: WAST (aaS /piF ! U;Pmsh f <br /> Address: 5100 Taylor Court- City: curlocK Zip: 4538 ] <br /> Phone y: ( 100 ) tq N ) — 5 S y q <br /> Date Tank Received: <br /> Name• Title: Signature: Date <br /> ....i....r.....................\......r....far....a...if..........r....r.#.ii....\....................... <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />