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..i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />##W##W##WWW++WWWkW##WkW####WWW#W#+#####W##W##WW###W######WWW#+WW###W###########WWW#####k######WWWW#WW#WWWW# <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: �'•/ OOIe war A !:04 F `1� <br />FACILITY ADDRESS: J 7 '74F /9" +ai •C,jiwa�-i n JIF i 0� <br />TANK ID #39 - % TANK SIZE: /0400 PREVIOUS TANK CONTENTS: O��EL Ff�Ef+ <br />+*****++++**++*+++#+WWWW*#++WkW#++WW*WW+++W*##W+#++WWW++WWW#++W*k*+W#WWWWW++++++++++r++++++W+W++++*++*+++++ <br />SECTION 2 - To be filled outbytank removal contractor <br />Tank Removal Contractor: 'J �� ��s�✓4P' �►.� <br />Address: -502.6 Z/ Avg '` Z03 City:$T� Zip: 0J Z' a <br />Phone k: (.76f) fSW -0103 Date Tank <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />A-e ei�i%iatmae.� �� � <br />Address: W4 Z/W41V�' jfCity 4��� Zip: 40jrW40 <br />Phone N: (jW9) 9.5 <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 />W###+##W#WWWW#####*##*WWW#W##*##*###W#WW#W##W#W#+WWWWWWW#W###+++WW#WWW****#**+*#WW#WWWW#*####W#*#W######*Wk <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or pipping. /� <br />Facility Name: W_%WN �`�-�� )•� �Wa�p�'� /� <br />Address"+�c/v Al. Wi/�-/x)_60 7 j� City:40,44we0••- Zip: 7���C� <br />Phone N: t`Q7) ep 6 2 �3 �6d <br />Date Tank Received: <br />Title: <br />#W#W+WW+##W++++++*++WWWW#WW+#W##WW++#WW+*#W##WWWW++WW+#Wk*#WW#WWWWWW#WW#WWWW#WWWWW+++**+*#W**W+W#*Wkk#WkW <br />EH 23 046 (Revised 9/11/96) Page 10/7 <br />