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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON,MIENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> »#rr*+r+»xxrr»r»xr+rrrrrr»»rrxr+r*++xrr+r++*#+++r»»++r+*###x»++++rw#rw*#rr#++###r#»#+rwr+++*»++r»xr+wwwrx++ <br /> SECTION 1- Public Health Services Environmental Health Division Tank Tracldng Sheet shall accompany each tink 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. �Il{__ <br /> FACILITY NAME: P'Zp PO S E iJ /1s S i E <br /> FACILITY ADDRESS: 2-9 6)Z P c lz r WA- � STDCAK­te�,fJ , cam} �I S <br /> TANK W#39- 7�5 1 S 631 TANK SIZE: S Do c,—(- PREVIOUS TANK CONTENTS: UN4hlcu t.) <br /> +r r++++++#»w#»##*w#»xr+r+»r»»r»+rrr»»»»rrra#wxrr»»r#r»w»»x#rrwr+wr»»»»»r»»»»»»»r»rrr+x+wrr»»r+xrr»rr»rr»rx» <br /> SECTION 2-To be filled out by tank removal contractor: <br /> I 9 / <br /> Tank Removal Contractor. ;,per /o 'F rC: <br /> Address: / PO/c) /'! ry i e� vlQ &` cv City: �n�..Q,y� Zip: 5V57-. 3 <br /> 11 <br /> Date Tank Removed: 1?r i/ /s�ti c0 2- <br /> SECTION <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: IV/ <br /> Address: City: Zip: <br /> Phone#: ( ) <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> mamer as required by Cal EPA. <br /> Name: Title: Signature: Dare <br /> +rrrrwr+ws+rrraraasaaaaaa»r•»»r+»+r»»rar+wxw+r#»w»r»+#r+*rxwwrr#ww+#r##+++rwrr+rxr+xx»rrrr#»+x*rrr»#r#rrr## <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting and/or pi mg. <br /> i v <br /> Facility Name: fj11 <br /> II Address: City: A_ �"o`�„ Zip: <br /> Phone#: <br /> A <br /> Date Tank R ceive& 5 <br /> Name: ` Titre: Signature: ---t---= � <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> f <br /> 7 <br />