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u I.W SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: 4/ 40 FACILITY ADDRESS: JI 7 A7�i� �/A l A�� TANK ID #39 - IZ TANK SIZE: IOG?^b PREVIOUS TANK CONTENTS: 41W 4i4CIAC/4' ##t####t#t###tt#t#**#t######t#ttt#####t##t###tttt#####tt#####t#tt#####t#########tt#########tt######t###t### SECTION 2 - To be filled outbytank removal contractor: Tank Removal Contractor: �J —� 4 V-�T�� Ie0' Address: -502-6 LpR'R,41046 Ave Z/ -0 -3 city: 97arA "".) Zip: 4p5-7.140 Phone N: (?( ) �J'4"d jQ� Date Tank Removed: *#t*x*#*###t*#****##*#t#*x#######*##x#*#*###*####tx###*#**#*t*t########ttttt*x#*#*####t***#####t###t*#t#*## SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: $.4c ��"R�� r/� e0400Address: 024 ZOM41yi= / 2J� City t�y1C:.� Zip: � - 40 Phone N: (44Q9) 9.4-07-0.3 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Title: Sistnature: Date SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: WPS7- e2 )9�1TTom.) /� �r AddressAW A • r�/!�/1/fp�% City:%VRLO�K• Zip: 7��7&OLO Phone N: fZOy) for Date Tank Received: Name: Title: EH 23 046 (Revised 9/11/96) Page VS