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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACING RECORD <br /> ++++ii#i#+#i+i#*iiwrtirt+Aii#rt+iirt+irt*wi+ii#####iiirt#+i+i###iAii#rt##+#######i##rt+iiii+##+###iiiii#i#iii#++i#+ <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. <br /> FACH_ITYNAME: �' ITy © r' 7F��y ® �/iE� � CJICK �iE <br /> FACU=ADDRESS: _369 61 /1 IA S7 FLA CC A 95-376 <br /> .�r� y t- <br /> TANK ID N39 - y A'O 51rJ 71 T TANK SIZE: 30d GAL, PREVIOUS TANK CONTENTS: G,450 2. 1 AlL <br /> **+i*i*+*i++ww*rti*#+i+++i+iiirt+++rt#wwiiiw++i++i+rti#+##+rti+Aii*w#rt++++++rt####Ai++iii#i+++iiAirt+ii++++#iirtii+ <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 1�R iG h1 T Fhi V i F O Al h1l N T/}L SEpw i c ES -TK C <br /> Address: 707 E, // Y�A S7 , Si7Irc /;Zv City: TPA'C/y zip: �;',�376 <br /> Phone d: ( s�_o 1? , 833 — 67S`8 Date Tank Removed: <br /> T— <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: W RIGfif l,i Y7 N7bA/ �x7�9� +�lr / <br /> Address: / E IJ``ySt I t),3° City:�Yladll Zip: ��U7 <br /> Phone N: (2?b 233 07S( <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: _Tf f r DQW ASS Title: P90J C C 1 g, Signature: �i, <br /> Date_ / 7 <br /> i*rtrtirtrti++iiirt#rti*+wrtrtirt+####+*++iwrtrtrtwww#i#rt+rrtrtwrt#rtwrtw+rt+++##rt++#»i++#+#ii++w»»Art++»wiwAA+*#iiwrt»w»i*++ii <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. �r <br /> Facility Name: IA1 f,6T C.0A5-r Y�it i�/YtPs1 <br /> Address: ,611) to ;yv/,(/ City: Zip: Sri <br /> Phone q: <br /> Date Tank Received: — <br /> Name:�0y, t, 4i Title: Signature-e- <br /> ignatu Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />