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02/20/02 13:36 FAX <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENMONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />M1 <br />rrrssa#rr+assassssrrrrrrasasrrarr•asaas#rrrrrrrrxssssrarsrr+rrs++»sar#rrrrrars+»a#wwrr+rsw++sssssssssasaar <br />SECTION 1- Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sbeet is to be returned to Public Health Services Environmental Health Division <br />within 3o days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and retumed. <br />FACILITY <br />FACILITY ADDRESS: 1111d s <br />TANK m 839 - e) / TANK SIZE: /DPREVIOUS TANK CONTENTS: tZI C c <br />+rr»«srrYrwrrrs»sssrrrrrrss»frrrrrrr+ssssarrrrrprs+xx�ksrrrrr+rM++ssa#srr+rax+xssrrxrr+rs+xxxsr*rrr+r+r+rrr <br />SECTION 2 - To be Filled out by tank removal contractor: <br />Tank Removal Contractor: v <br />Address: City: zip: 7 <br />Phonef: ( , St33 D �? S $� Date Tank Removed: <br />arrsssssarrra*r»ssasr+rrsaa#ararrr«»sa::#rrrrarxrrssssrrrrwrr+rxsas#rrrr+«xrs*rrwrrs+arias*ryrrrrw»rsrrsasr <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination <br />ti City, J _zip: 7S-3.2 4.1 <br />Phone g: (24A ) SS :?h 3 — 62 113: <br />Audwrized representative of contractor cenifvin2 thmueh signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name. i - <br />rrrrsssarrrars»asrrwrrssssarr <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: <br />Address: <br />City. /nom � Zip: 9.!Z-3 730 <br />Phone <br />Date Tank Received:_j <br />' Name: Tide: Signature: Dace <br />.:.srrar•s:srrwarsssrsarr•sass#rr►«•a:srrrr•»ss:rrrrrrr+x+xxaawr+raaxxrsrrrrrw+assrrrr+as»srrwrrr+rxa#rrr <br />EH 23 046 (Revised Og/13/99) Page 10 <br />