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�,,6AN JOAQUIN COUNTY PUBLIC HEALTH`-ftRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> }fiefftfffftt}}if i4ffitrtik}t444f 4k4fftrtt4ti}i}tttttftf tf fttttttk}ort#ikrttkrtki####ktik4#4 ikk44l4MikW!#4#it{#{} <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 returned. <br /> FACILITY NAME: /9 �?� 0 6�- <br /> FACILITY ADDRESS: ,?_h�_/g 1-1,0/h MI r <br /> TANK ID k39- 7 4'31-6 I TANK SIZE: PREVIOUS TANK CONTENTS: un/ j//1j y/,;V6 <br /> kk#k4kk Wk Wk#4#tWWWWWWkkFktk#ikkkk###kFWkkFkW44#4#W4W###FWFWtWkW###kkkW#4k{t#kk#ikW###kk#tFi##ti4ktk{kWkt4Wk <br /> SECTION 2-To be filled out by tank removal/contractor/: / <br /> Tank Removal Contractor: C 46. LI//lJ'i S //J 4 STjt2( MAIM �0 -nn Zile/ <br /> Address:/'TDD CU 6&ew Q0l Cit,41e 4&ly Y'A- 713,w <br /> Phone q: C&6-)-r qd?ANIZ 9 Date Tank Removed: <br /> kkkkkkWtiWltk#i###kiRFF##it#WWW WWkWkWWk4kkk4###k##iiittt#tttkt#k##W##4#kkti!!##kk##WktkkltWWWttkFikttlttkWW <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone q: L_) <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: Signature: Date <br /> iWtkFik##!i#4#4lik######k#{##WkWkWkkkkrt4#WWtiWWks#rt 4rtkkk4kWWtkk#skWWWk Wrtk#rt#i#i#Sirt##k4kkkkikF#tW##Wk#Wlk4k <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 /> J <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> {kWk4tkkti}{kkk#kk#ktk###t4Firtki##ikkkti#kktttt###}ki#k#kFfFff#f#f#ikFt}titiiiit#ikik###itktttkt[kF#t#t#k <br /> EH 23 046 (Revised 08/13199) Page 10 <br /> t <br /> i <br /> i <br /> OM G <br />