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I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> Y4ittYrtiY#}VY#####}##Vii#}YiYii}*Yrt#YY##lWi4YiW rt++4rti4!#t*rtiYWtWrtYYWiWYWYrtlWi#*Wlrt VYi*+#YY#WtiY##}#lWiYt}ii <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 /> FACILITY NAME: f2f="— EA--LL— r( <br /> FACILITY ADDRESS: " 'C 14. k-T C\tt.-i— <br /> TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: <br /> iitt}+}#YY+#}iii*itW*+Yt+#V###t#!#•;i#Y#irt####ii#*####i####rt#t#iW#rt!i#firttrtYiti#rtW#iYit*##it}rtrt#t}###}i##fiY# <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> i <br /> Address: City: Zip: <br /> Phone#: ( ) Date Tank Removed: <br /> itiir#V#iirti#lYt+#WYtii#Y##rt*rtii YWrtitrt#W##VVrt##ttYYW*WiiWYt4Yt#irt}+fi4iY#rtrtiirttrtiW#YrtlWrtiW##+titiiiirt#rt#Yi*i <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 /> SECTION <br /> ateSECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> I Facility Name: <br /> i <br /> Address: City: Zip: <br /> Phone#: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: -Date- <br /> EH <br /> ateEH 23 046 (Revised 08/13/99) Page 10 <br /> I <br /> i <br /> I <br />