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.. <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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. <br />FACILITY N <br />FACILITY A <br />TANK ID #39 - TANK SIZE: OC) PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractorc�7tr <br />Addressg�o & b,. U."1' t Col� City / o�lC� Zip: 7j -?-C -f <br />Phone /t: (�j ) ectI F -73z-3 Date Tank Removed: <br />SECTION 3 - To be filled out by contractorr "decontaminating tank": \ ,o <br />Tank Decontamination Contractor. ,,- � �x,-r t cfc gr*-- l�nJ <br />Re <br />City s;- Zip: 4-s'Zelf-- <br />Phone N: ( 00�) (6sf— R 333 <br />Authorized representative of contractor certifying through signature below that the tank as been decontaminated in an approved <br />manner as required by Cal EPA. jI � _ <br />Name:/(41 Title:i%L�J11J252Signatuk. t J — Date1. <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 <br />Address:%OO W-9. NA-ceu a� � City:—raf2COck- Zip: <br />Phone N: <br />Date Tank <br />Signature: <br />EH 23 046 (Revised 9/11/96) Page 10 <br />