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.. <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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. Q <br />FACILITY NAME: _�i t �dM �B 1' R A,,t 1 I n <br />FACILITY ADDRESS: �'k N'67 14-4 ,t SI,2 / �, QTA�DW % dAt 9riafS�i <br />TANK ID 1139 - 61 TANK SIZE: 35 D PREVIOUS TANK CONTENTS: ►+ID.N � <br />#W####W################W########WW##WWWW***###*#####W#W##WW#W**##*#############*##*####W####*##W*######W*** <br />SECTION 2 - To be filled out by tank removal contractor: �y� We <br />Tank Removal Contractor: DEI—Imp- uGv 1 U`[r r 1 <br />IC- -591 <br />t <br />Address: �b�� �,1L+A OE %MJ C 1 City: Lip: , 7391 <br />Phone A: (�C _) 94-7 9 ` S % Date Tank Removed: <br />#############################W###*W############################WWWW##W#WW**********W*WW******W######W*WWW** <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor0CL7L_U+ �, _1EU4'✓\ IC*t- W`Fi:T <br />^�7 <br />Address: D 0L rnQUOS �E , City: Ury }-mat& `�ip: <br />Phone N: ( b ) 25� y7 g'� rA <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 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: 4 4-S EXA-L5 <br />Address: b 16 A-AkIRID w &I City:I ■'� D F 1 �'t C*.-: 15351, <br />Phone Ji: <br />Date Tank Received: <br />Name: Tide: Signature: Date <br />#**##W#WW#WW#######*##*W##W#W*WW#WWWWWW###WW#W############WW#W#WWW##W###############**###*###*##**#####** <br />EH 23 046 (Revised 9/11/96) Page 10 <br />