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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #♦*W**WWW*Wrir#ii##*tWr##fiWWi#firtWtr#WtWi#rtiWWi#i4Wirit#W#rtr+W#rW##Wirt#iWr#*fi+r#Wiq#rWi#*rri#rt#ilii*rW##iW# <br /> SECTION 1 -Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and(..�/r'eturned. I <br /> FACILITY NAME: [l IE�tJ 1142 CA 0 VIS t� <br /> FACILITY ADDRESS: E I Z -7 Fie <br /> EMDn) <br /> TANK ID 1139 - TANK SIZE: -�){ I PREVIOUS TANK CONTENTS:_(& <br /> #*+ii#rtrt#rtrtWilrtfiaiiWirt#r+++ii#fir#+i#fi#*rW##fiirRJfi*iirr#+WW##++r#rtrt+rt##*WW#fi##Wrt#r#rt*+irti#WW#++WrttrtWrt+rtrtt## <br /> SECTION 2 - To be filled out by tank removal contractor: AA <br /> Tank Removal Contractor: AN ED 6L09Al[) rVa tA1eA/tt L <br /> Address: 4O05 N1 W LAN <br /> or _ City: S70o>\' zip: <br /> Phone#: ( �Q� ) 7�U7—l W Date Tank Removed: <br /> fi#W#tWWW+I#Wirt##t*i+WrtW#i##rt##fi#+Wirt#rtrtrr+iW#rtf**Wi#*rti##rtrt+*##rt*t*##rtrWlrtrt#+l###++##riirt#W*rifiiit#+rt#t+ii <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: AD-VANC�n (7t0�N✓IM/JM –fT/JcC— <br /> Address: ¢00S /V �/ L SO/y (JA�� City: SV C–k MA) Zip: Q S Z o S <br /> Phone ✓1: ( 7jA ) 467—/00(p <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> maturer as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> i#iiiri+r*+i*+WWW*W+r+i*++**+rWri+WWWiiiWii##irti#4fifiitiW+iiiii#lit+i*+ii#ir#*#*tWiirtrtiriiiii#fii*Wlirt++ii#fii <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: <br /> Address: City: Zip: <br /> Phone q: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ilii**fir*trtri*i+++rrr#fi##riiiWiiWWrrrirr*rt+trlt+WWWr+r#i#rt#fi#rtfi##rtrtrt++r Wrrr#rtrt*i+r++rtlrti*r++ririfirt*rrirrt+ <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />