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M <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />t#**#**#*****+##**w*#t#**#*###***##**t####*##w#tt##*##t###**+#**t#*#*ww#*tw##tt####*+tw##w*t####*t###w#*ttt <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 comfpleted and returned. <br />FACILITY NAME: 1coO©Car <br />FACILITY ADDRESS: J 1 7 -F d" «.37 4Lj/t►'W-4F 'y - % 'F-' <br />TANK ID /139 - S'O= fTANK SIZE: /00" PREVIOUS TANK CONTENTS: <br />*ttww#*ttwwtt++###**t#t*t***w*t++**#tttt##*t+ttw#*t*t+w*t*+wtttt*+w#wt+tt##tttttww**++++wwt+++t++++*+t*#w#t <br />SECTION 2 - To be filled out by tank removal) contractor: <br />Tank Removal Contractor: 8"e `QI/i�.�ai� Q✓ ���li� `y <br />Address: -&02.6 L.0AW4441y46Q -'A Z/3 City: S7 -ACA* VA Zip: 995-ZA0 <br />Phone N: ( .24W) f4rdd —CO gO: Date Tank <br />w#tt*wwwwttt####**t+*w+*t+*tttww*#***tt#w#t#*+tt#w*#**+tt###******+wt+++++*++*+*+t*+w+t+*+tt++ww++t++*++*#* <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: A e CONS 6�� rv*$°4' 440 <br />Address:+4 g424 L�.pyKr�l7h%� ArJ�3 CityyG' IIU Zip: #VS W6 <br />Phone H: (4W)QS4-l%Ld� <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: <br />Signature: Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank 6and//o�r�piiping. <br />Facility Name: Wk:57 6453'7- <br />' 43pie� <br />Address -YA" A • WII_'��/� 4V, City:r&%R�.©�� Zip: 9sV&a <br />Phone #:1409) Q7) to Q 93 <br />Date Tank <br />Name: <br />Title: Signature: <br />Date <br />tt*t++tt+tt++++++#++w#w*ttt+#t#**t+twt#wtt+#*#*+ttw#w*++*t+tt++tttw++t#+w#*t*+#*++++tttt++tt+++t++++wtw#w <br />EH 23 046 (Revised 9/11/96) Page 1013 <br />