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*Ar <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />PI�(EI Td I�i✓N)OV� lST-(NGr TM KS hor TO ge:MAtlo) <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: _/ imu erwicz s RTI oI l ^ <br />FACILITY ADDRESS: <br />TANK ID #39 - _I_TANK SIZE: PIPIWk ffid PREVIOUS TANK CONTENTS: (2{S uCmD� <br />SECTION 2 - To be filled out by4ink removal contractor: <br />ITank Removal Contractor: <br />Address:11-33S JuTV4 HPaLAtJ kbtir0 <br />pipikle <br />Phone A: (_209_) 2S4 —2450 Date MaitRemoved:- <br />City:Lp�,DiR4 zip: '15330 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: G.G.- . <br />Address: 255 PAR& &- City: RICQ_ zip: 9490.1. <br />Phone N: (510) 2;5-1393 <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: <br />Title: <br />Signature: <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: E-. C. _S.._ <br />Address: 2Ss PARR City: Kicwn0t) zip: 94BOi <br />Phone R: (5117) 23 5 - 139 3 <br />Date Tank Received: <br />Name: Title: <br />EH 23 046 (Revised 08/13/99) Page 10 <br />Date <br />