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OWA <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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. <br />FACILITY NAME: <br />FACILITY ADDRI <br />TANK ID #39 <br />0-2, TANK SIZE: D D kAC. PREVIOUS TANK CONTENTS: 68'�PLItrt, <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: �L-Te- A,A ��+ryL� t,� iAp e M� p 7 7 <br />Address: (� S �� oL.�u� JuFI City: G1W by ip: 1�701 <br />Phone : () K4-7 gI%I Date Tank Removed: <br />SECTION 3 - To be filled out by contractor -"dce�cconntaaminattiing�tan]k"": <br />Tank Decontamination Contractor: bE 1 -Ct6 a -y oV1m (C4-t� Y�'p� <br />Address: ( b 13 )-1b-`'C <br />I t 6 -1 b1E 0f % City: AV-0ALe Zip: `1 361 <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: <br />Title: Signature: Dare <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: fL�; <br />Address,b osLD WRy City: Ztip: � <br />r <br />Phone (\\-- 3-7q7 bU <br />Date Tank Received: <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 9/11/96) Page 10 <br />