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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ..................a.......r•//rwrYiirr/rYr•airr.VaYrYii•FYr/wwYirrY/♦aa•rr•rYrrY/V.V•nrrrrrrrrrr•/rrrr•wr.. <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site ideniffication 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'r6ponsible for ensuring that <br /> dus form is completed and returned. <br /> FACILrlYNAME: LIBERTY FIRE DISTRICT <br /> FACILITY ADDRESS: 24124 N. BRUELLA ROAD. ACAMPO , CA 95220 _ <br /> TANK ID #39 - TANK SIZE: :?a_i:� GALPREVIOUSTANKCONTENTS:_DIESEL FUEL <br /> ..........................•ar Vr/rrrrrriirrrrrr/i•/rrriirr/•rriiYYwarrr//••(rrrrirrrrir.airgrrrrriprirrrir/ <br /> SECTION 2 - To be filled out by.tank removal contractor: <br /> Tank Removal Contractor: JAMES J . HOBLITZELL <br /> Address: BOX 30331 Ciry:STOCKTON ip:95213 <br /> Phone p: ( 2 0 9 ) 9 4 3 7 7 9 3 Date 'tank Removed: _ <br /> ...............rrr..r.....r...••♦/rrrrr/Y•/Yr.rr/•rr.rr•••.wra♦r•///wwr♦r/+♦/rwrrrrrrrrrrrrrrrrrrirrr.•w•i. <br /> SECTION 3 - To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: JAMES J . HOBLITZELL <br /> Address: BOX 30331 — City: STOCKTON yip: 95213 <br /> \\ <br /> Phone q: ( 209 ) 943 7793 <br /> Authorized representative of contractor certifying.through signature below that the tank has been decoa" ted in an approved <br /> maturer asco <br /> 1 re red by Cal EPA. / — z <br /> Name: J b WzZ Tide: 1/ Q� Signa[ure: a fj �f if UJ <br /> .....a.r........Y.//••...aiiY•rYVYrrrY•r••rYiV.r/iV///YrVr/r♦♦rYY•rr Vrir/rrwi r ♦irrlrrr►rrrrrrrrYrrYrlirYYi <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facuiry <br /> accepting tank and/or piping. <br /> Facility Name: <br /> � <br /> Address: I2__ /( I [� (` Ciryj: �V�.L(�J�'' zip: l I <br /> Phone p: ( ) w L (11 0 _—. <br /> Date Tank Received: ZYJ <br /> Name: F`��nr r-e�� Tide: / a- _,_ Signature•- _Date <br /> a.................i.....r..rrir/irY/•iwir/M1ri..u •rr//rriir•.ai/r.•/iiiYYi••/a/iirra6 Y..wr•riirrrr•ririr•w♦ <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />