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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 with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> rLhL30 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. <br /> FACILITY NAME: 0 /7y O F� TSR C y /5_.h rZ/''tCP_ rfL.e7 g o'e <br /> FACILITY ADDRESS: J 6 ® E . i f .th Sr 10 T(LA C y s C A 95-376 <br /> TANK iD#39-fA'O 515 717 TANK SIZE: 3 d O GAL, PREVIOUS TANK CONTENTS: GA SO L I A/FR� <br /> SECTION 2- To be filled out by tank removal contractor: <br /> Tank Removal Contractor: W(ZIGHT Jr�NViRON1A91,-;TAL <�g1z_V10ES _T,►dC. <br /> Address: 707 E, // /, .5r, Su/fc /;ZT City: LEA y Zip: !?S_376 <br /> Phone#: (_;O 833 Date Tank Removed: Z, ��lf <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: IrJRyG#� !)i x)rI�p[i(ys..- Ino . <br /> Address:�-7 E ��1rJ��, (� /p�� City:`MW Zip: <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. I /J <br /> Name: Sf r f VV WA✓� Title: 12)x':C C 1 �(�je, Signature: Date_A <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:_�/ Irl L 5 i LO A 5 T it Q1)i�n� <br /> Address: 5y ` ) _ iy�/ / ` V City: U Zip: 7 <br /> /y� <br /> (Y 5: <br /> Phone #: ( ) � - D <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />