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\.6AN JOAQUIN COUNTY PUBLIC IIEALTII`4RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> twf44kf4fil+if 44i 4444rtti iYYt i4 t++trt4+f+f+lttrti4frtf4Yt 44 Ytt ititkk4k+#4Ytkkt WRi##i*ttit#kk####kkt##t#Wi#ik#i4 <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 da vs 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: 0�qeno <br /> ly- <br /> FACILITY ADDRESS:%3—,mog 'e7 <br /> TANK ID q39- : 3J O ZTANK SIZE: ja/)DD PREVIOUS TANK CONTENTS: <br /> #*;W4#4*4W4W#;iWtrtttW4#Fkt*ti#k4W#4;44;##t;#i#Wi;WWrt Wt Fk##{4iR#rtk#;;ktrt#;rt#t4{{rtW#W4;kRk#kk*#k#t**##*t4444i <br /> SECTION 2-To be filled out by tank removal <br /> contractor:: <br /> Tank Removal Contractok/E, 1/ ��S /& <br /> AAWIS&AI Al <br /> Address:/700 0a Q/0/ CitymealAayyn-���((eQ <br /> /,3p <br /> Phone <br /> Date Tank Removed: <br /> ###iiii FRWi;k{iW#liiti#ii##i#t*Yi{;{{i##iii R{;ii{4*t#i#ittii4;4*trt#Wirti#;W##;;i;;{{;#tik4t#*##iik4#►W#i444i <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone#: ( ) <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 /> tW;##4#rti;iik#WWktkk#iii#tki##Wi;R##{Ort#iW;iiR;rtit#iitY#{kiiii#;;;ii##;;i;{#{{t;itWi WR{#Rkii##4##*iii##;;;# <br /> SECTION 4 -To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> j accepting tank and/or piping. <br /> Facility Name: <br /> Address: City Zip: <br /> Phone p: ( ) <br /> i <br /> i <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ki4##4t#{#tint##tkfWt4Ytt#tittrttFti##W#rtkY#RR##Wt#RiitR#t#tRR4ifiitittiittt;itrt4##{ktkk##tWtk R#t#ttt#trti <br /> EH 2i 046 (Revised 03/13/99) Page 10 <br /> i - <br /> i <br />