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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> / ENVIRONMENTAL HEALTH DIVISIONV UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #irrtWWirtrtW*WW#*#i!W#iYW•rtfisirtrtrtrt WrrfiiYrt!!!!ir*rtrtrt!liWWW!!rtW}#rtfiiWrt#fiYWfifiY#WrtY#WirYrtWrfifii4WWWYYiifirt4fiiiiWWrtW <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 NAME: ts0r) Tj(Qld IVl c�tlf-� l- �IPltfOr <br /> FACILITY ADDRESS: /q5q rlw(+D 6ttr .Frm PA 95a0(o <br /> TANK ID #39 - TANK SIZE: 8"1000 PREVIOUS TANK CONTENTS: <br /> riWWrtr#Y«#WWWfi###W W4WYrtirfiWWrt4}4irYi#fiWlrt#444#4filrlrtr#fifi4YW WWW4Yti#WrtlW4irfiYWrtl44YWW4W#W44W#fiiW WWl4rt4#r**!rt <br /> SECTION 2 - To be filled outby <br /> �X('/1by tank removal contractor: <br /> Tank Removal ICoontractor: 1Q ir+- ahjDa ('9 <br /> Address: d� I city: _Zip: <br /> Phone d: (� ) 'a Date Tank Removed: T <br /> #iifilrlrtfififi!«Wrt4tl4«fiWWlirt4lrtY#}iiirtrtlrtW#Wrtli4rt**i*firtWl;44iY«YYlWrtrt4rt4#fi##r!*4444*iii«WWrtrtrt4fi4i#*!rt!rt##ifi*i <br /> SECTION 3 - To be filled out by contractor "decontaminating tank":: <br /> Tank Decontamination <br /> _ Contractor. � I'— o na i1c � <br /> Ci : � <br /> _ Zip: qJ� f(DAddress: r " / <br /> Phone p: (_C 'QZ4-7 <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 /> rilrtrtrt##44fiirrlrtlti44#44#*ir!lirtrtrtlrtrtrllriiii4!!*rtrtrt444#irtrtlfirtWW4rt#4Yi4ii#Wfiirtrtrrt!#4#«Yr#rt!Wlrtrtrt«#irtrtWWW4rtrt <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: Webf l nca,,of f l�u G <br /> Address: City: "-rt rloc i~ Zip: q 538a. <br /> Phone p: ( Z q) W a K-q3 U( <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> #Y**WWrtrt#rrfirtrt#4YY#W4rrfiifi#rtW#4WWY#YrirrrirfiririrY*WY#YWW*W WWWirtY#WWW##Yrfirr*riYW#YYYfiYYYWYYrY#WW#WYiYrYY <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />