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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.,, `` l <br /> FACILITY NAME: ej� M ctiA_C t i 51� `�fl1 d \ <br /> FACILITY ADDRESS: <br /> TANK ID #39 - 'G(TANK SIZE: SC&p4 ��REVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: (0,-? F I � S � E'� City: \ Zip: <br /> Phone #: Date Tank Removed: 1 <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor:� �� 1 �HV��OV�YY�L lata—\ �QCJ �C eS. ��• <br /> Address:Ln_� �. I �4� c� j City Zip: <br /> Phone #: ( ) ��7) — O`Z �� <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: <br /> Address: QGC) N. Zip: e4S3�cSO <br /> Phone #: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />