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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> IENVIRONNIENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I- 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: car pee �er GO . <br /> FACILITY ADDRESS: �� y SC7u 1 �s `An o QC <br /> TANK ID#39- ® TANK SIZE: /0,006 PREVIOUS TANK CONTENTS: e 5 e <br /> SECTION 2-To be filled out biy,tank removal contractor <br /> V : <br /> Tank Removal Contractor:_ A U P—S n A 1 f)e e f f r\ M _ <br /> Address: Lucerne- Ave City: S+oc, C+Of1 Zip: 9So2� <br /> Phone#: (.20 9 ) `F69 y-o10/y Date Tank Removed: <br /> 1 <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: V Q l u C <br /> Address: 1(95_7 L V c et—n C A City: S fto,k 4-on zip. 'Sao 3 <br /> Phone#: (oZ 01 01 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cat EPA. <br /> Name: Title: Signature: Date <br /> SECTIOiti 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. c <br /> Facility Name: V+/25-� Co a s G 4 u i�p m e n+ _ <br /> Address: 151-10 Wes+ L.- n e coo to Ave City: TVr j o G K Zip: of 5 3 So <br /> Phone#: (X I) &)68 — j 9 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 045 (Revised 08113/99) Page 10 <br />