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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONM NTAL 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 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. j� _ /N - /� �. f <br /> FACT ITY NAME: � s(�` SSC (` r � u <br /> FACILITY ADDRESS:T�yL3 d <br /> TANK ID#39 71 <br /> - � p TANK SIZE: PREVIOUS TANK CONTENTS: Ic:ia L <br /> SECTION 2-To be filled out by tank removal contractor: <br /> r. � ot <br /> Tank Removal Contracto ,/r. gy, 5_ � <br /> Address: �$I i F-c7rc City: - Zip: 2 0 J <br /> Phone#: (�> f[b7)R-"/o- Date Tank Removed: 1,�, Ro,_ /15/5 <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone!1: (_) <br /> - Authorized representative of contractor certifying through signature below that the,attk has-been decantaminatcd in an approved.- <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date - <br /> s*sssans:##a»sssssii»*:::sirs#»»sssa##»iassssaass#iii#»#»saasiaii»#�»iia»nail##»#»ssssisss##i»»»»»»a##»##»s <br /> SECTION 4-To be signed and dazed by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: WA44 7— <br /> Address: /c7D 7A, ,e City: ' l,� Zip: <br /> Phone il: (1y4 > (04f 93 7(�' <br /> Date Tank Received: A <br /> 1 <br /> Names ;,-KE Title: Signature: Date�- <br /> itsss##a#nasi#a»»aaaaa»asassssiia»assiiisiioil' <br /> »ins»*»»sssssi#»s asa*ala#»»aasaas*#asaasss*x****s**xs**** <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />