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SAN JOAYUIN COUNTY PUBLIC HEALTH SERVICM� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ##rrtrsp4*t*##t+t*i#strt#tier#irt#*##*isr»rr*r*#w►tasrr*#t#tr*r+#riri#rt*Riwrsrrs»r»#rwiaiwts##rsrwr#rtrtw4rt <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 /> FACILITYNAME: A. Teichert & Son, Inc. <br /> FACILITY ADDRESS: 103 North E Street Stockton, CA 95205 <br /> TANK ID#39 - / 55!5-6 TANK SIZE: 20, 000 PREVIOUS TANK CONTENTS: Diesel <br /> ir#►#4►sRRR4*4#risirrr»r»r►►s►ir#i*#4i#it»rwtrir4+k#riir#ii»#t+rtiisrt**rir*trrrr»►sr+R#kkkrr#srst*s+wtt»■i# <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 /> #tiwrwirwrr*rtk#«+***rrrss#rrs#rt#«i*r***s#*##str«*rt*•*rrk+rr*riii#i##*#rwrrkskis*irr4rswrrt*kr«iiwtw#r#4+rtir <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 /> r#rtkkRkk*kkkrii«irtr4##44r##r*»s4#s#*#rtrtr**rt**4R#krR#krk#4ikk#k#i##rr#rt#rt#Rrt*#**r*»#*#4R*rkt*##ittrrkrkM#rk <br /> SECTION 4-Tn 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: Signatum: Date <br /> Orr+w►r#*r»»rrt*trr►srswwwtwtrwssrrrtwwrtwsrrss►srs►s»rrrsrs►»srrrwrrwwstr►r►q»rrsrrrss»r»»r►sras+s»»*t <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />