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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*********************************************************************************************************** <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 Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 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 returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: / a S � <br />TANK ID #39 - _TANK SIZE: /O PREVIOUS TANK CONTENTS: I et5 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />�0 7 <br />�� <br />57`/ 2CY City: �d uc�Zip: <br />g� <br />V <br />Phone #: <br />( el -6 <br />x'33"07 S <br />Date Tank Removed: <br />*********************************************************************************************************** <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Z4,1 <br />J ri g A <br />Address: 674--, 1Q ='f City: Zip: % <br />Phone #:(24 ) $32`62 S $ <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. --- 1/� <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: /ZZ/ S %�yo �ac city: _/s�o�� Zip: fry <br />Phone #: () 6 7 <br />Date Tank Received: <br />Name: <br />Title: Signature: <br />EH 23 046 (Revised 08/13/99) Page 10 <br />Date <br />