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s <br />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 <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 />/ <br />FACILITY NAME: t/ 04Are�r 00 4Z <br />FACILITY ADDRESS: J ��� P a�T� R✓A�r <br />TANK ID #39 - t>SOZ �� TANK SIZE:�ODOO PREVIOUS TANK CONTENTS: 40. �� <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: &0 Lp�QA��E A(JC G•/ City:.,P Zip: QJ Z O <br />Phone #: (Jl ) �4"d j� !� Date Tank <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />A�.y4f ,�/Y_1�,,y7 � � 400 <br />Address: -TJO24 ZOJW414 4— 400 1024City Zip: O'5W4 ) <br />Phone #: (APP) 9;S -4_0Z0,3 <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 />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: kIC— ng�7—e� ;4 ,T o; — �) /� <br />Address7dW Al. Wo%ifA)W 7 Ci y:T�fiRLO�L Zip: 75��4t <br />Phone #: ('7409)'i/) & t(2 OF" 93 ;T <br />Date Tank <br />Name <br />Title: Signature: <br />EH 23 046 (Revised 9/11/96) Page 10// <br />Date <br />