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'rXN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> +4#4rtrt44i##ri#rtirrtw4rtriki+W++4r4+wkWW44wrw#++rrt#+r#rtit#Wki W#ktirrt#w;WWWr+Wrt##kk»ki!#iY4iWkWkk4!#}»iW#kikk# <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:_9Q13n <br /> FACILITY ADDRESS: 4209 F. L�A/h iyyr e�j�/ <br /> TANK ID N39- TANK SIZE: PREVIOUS TANK CONTENTS: IA14� /a"I.;/C <br /> +####lFW;YYi!#Y}liii}}}}Ykli;kkli;kktkY;;;ikikk#k#ki»trt###k###kkfi#flirt#i#twit####ik#ttifi####k#kir#+r##rtr+wk##rtrtw <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> � e n /� <br /> Address:/W0 DIA/ 6/yem Kal Cit}r7Yttl� /y t?ocw <br /> Phone N: Date Tank Removed: <br /> ii}}Y}YY;liiYkfiili#tkYYYYYifiYYikiiiii}}fikfi#;4ik###Wri4tfi#kFkit######k#;#;l;}i#itis}t#ikklttiiili4iWliti#fii; <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone k: <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 /> iltfii##kfil;ikfi#iitkYt#k#k#klit!}}kfifi###fi#fikYfi;i#rfik#Y#Yt#}Y#iiilt#i;fifirt}Wrt#ki;iii#iiitiki}fifi;lttti###;##!;; <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 N: ( ) <br /> jDate Tank Received: <br /> Name: Title: Signature: Date <br /> kk;ilfi;!#ifili;li#fiikiifiYttirt##iw#4i#ti»ki»trriir##iir4ififii#k#lk4ifrtR#t#+#ilii#k##i#i;#liikrtr4tk#####W#;## <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> I <br /> ! A <br /> V <br />