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..o� <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 />FACILITY NAME: <br />FACILITY ADDRESS: 5,17 1 / A— .T` �r A ro '-'D <br />TANK ID N39 - TANK SIZE: LGiiO0 PREVIOUS TANK CONTENTS:SQL.IA,0`46 <br />SECTION 2 - To be filled outbytank removall contractor: <br />Tank Removal Contractor: )3oc �G/��' �T�/� ����©� Z'. <br />Address:026 �,Qte//Caiye Ade- -0 Z/3 City:ST� Zip: tps2/G <br />Phone N: (14 ) fr4-00403 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: &e py�,,�,Vr�+R��� ea �y,�r�� <br />Address:gw& Zo�i9ly� 00*00 1 City �� Zip: #* 40 <br />Phone N: ( ) 9;S 4-A!:0Z03 <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 Naame:__ 4:57— e/ 4� t3 x7_ �r3 <br />Address7dW Al.14144 6AV4 City:40,44W � Zip: 5 j D <br />Phone M: (2009) (+ 6 tI `" 1946 7r <br />Date Tank Received: <br />Title: Signature: Date <br />EH 23 046 (Revised 9/11/96) Page I(�` <br />