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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONNIENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />• ••.•...••••....•............*..*..... Rk44it R4Y4k}Rtk 4f..i.* .......................................... <br />SECTION I - 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. n <br />FACILITY NAME: <br />` FACILITY ADDRESS: 14, <br />TANK ID:39 - D-2 TANK SIZE: C"D ��( PREVIOUS TANK CONTENTS: <br />........................................................................ <br />,. SECTION ? - To be tilled out by tank removal contractor: y� <br />Tank Removal Contractor: �,-��I`t V�JT�Rt t\C.�L_ �F F M `r <br />Address (a ;O OL1UE- At1Ft city: _U11 �1�,S61 <br />` Phone =: (1)_ �jl }� �1�� Date Tank Removed:— <br />.............................. ..... <br />emoved:_.................>.>.........>t...Xi.R..»i4t,.R..}..... t.........».»................................... <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />` T'. -.k Decon:aminntwn Contractor: <br />` address: City: Z p: <br />Phone <br />Au,•nor.zed representative of contractor cemfying through signature below that the tank, has been decontarmriated in an apmo%ec <br />marine: required by Cal EPA. <br />IMP Name: v Title: �j'Y�(�'�i01�'D Signature: Date 'V <br />.... .......................... � ... *U .... >........................... <br />..}ttttR.Ri Rt.i Rt. .R. <br />SECTION a - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Fac:!in Name: At <br />r <br />Address ,6 b Ciry: <br />Phone ✓u 1 ) `) �i L { 1 b� <br />Dale Tank Received: <br />. .e �� /�'�,+�12.i1 FO YAOA:i�6j—T Signature: Date <br />.......................................>...>.»>.>.>>.>t>}.>:. <... »... >..>......................... <br />v <br />EH 23 046 (Revised 9/11/96) Page 10 <br />r <br />