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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I- 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. ItAnn nqII " <br /> FACILIT'YNAME: �P� SiccD A"IS tE .�-BJD�%S112A{�t- �fFR'1— <br /> FACILITY ADDRESS: ��z-`� J'- )Z PC i"Fyj&y Srnu� y� t S 2.b F, <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: UNy-Nc-)J <br /> ##rr#r##irkli#r*#####»x+!##■#rxl4#krrii#xilskits+r####rs#fi#ikfir#sk#x##isksrfi#iiiiixk###}r##fii#fi###i4fi#ix#ik <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone#: ( ) Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <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 /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> � #####rrrs!##1rrrrrrrrkrslrrr*r#r#+rl+r##rr*rsrlrr#srys!#+rs+rr#i##i#+#+!#k#+rr#»####!!»k##ki»#*s##si#ii###• <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: City: Zip: <br /> Phone#: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> #xi#iii#iixti#ixi#xiii#kiii#ik#k##*#ikiifi»x##ii+iii#ii#iii#ik4ki»i#iiiifi#ifiii#}iii#ik#fii###fikkii##i###k*# <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> I' <br /> 1 <br />