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..W <br />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 lank 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 />FACILITY NAME: MOdowu-p : epz F-UOIW7 <br />FACILITY ADDRESS: 5V A?/ <br />TANK (D #39 - JPZ —9 TANK SIZE: /aOO.0 PREVIOUS TANK CONTENTS: 6,�J:%LJ.yE <br />SECTION 2 - To be filled outby tank removal contractor: <br />Tank RemovahContractor: .J —Gf G �ST'e� <br />Address:0026 LojejemmE Aag "A Z/3 city:ST,g441y"-) Zip: 495W40 <br />Phone #: (1( ) VS4—d1O Date Tank <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: ;•lc ��/s'�'aQ�diiJ �d <br />Address: Z0y 41j0� � +� "City 40$W420Zip: 7Y <br />Phone #: ( 75-4 03 <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 <br />Title: <br />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:r-57—V • W44 <br />AddressAW , <br />Phone #: 4949) G7 81- 4943 7e <br />Date Tank Received: <br />Name: <br />Title: <br />EH 23 046 (Revised 9/11/96) Page 1014 <br />City:TyR40C1e— zip: 9S-&&40 <br />