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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: o Pncl <br /> S <br /> TANK ID 1139 - TANK SIZE: 2SL>�> PREVIOUS TANK CONTENTS'a <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> J <br /> r city: (raC�l zip: S3 7 <br /> Address:%4-n ` C�1�Y��FCY G \ \ S <br /> Phone n: ( ��°' )�J3-C-1 SL <br /> Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: W 1;� i <br /> Address: <br /> n P _ �t � City: Zip: <br /> Phone #: (2Cry ) - V <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> mariner as required by Cal EPA. <br /> Mame: <br /> Title: Signature: Dace. <br /> _###}=}#=fi..}.....####.......a.##=.fi.}.............#.#......#_}#_#_#}###}}}_}##__#}#}_#_#_....... <br /> ##_# <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: 1 <br /> Address: 1 1 L� s 1 ' ^.r\� CC C� <br /> City:�t c `Cc�k zip: <br /> Phone 4: (�c 11 ) Ll cT <br /> Date Tank Received: <br /> Vyzte: <br /> Tide: Signature: Date___ <br /> .....*#.........................................._....__#_........_'------- <br /> E-.j -'--. 046 <br /> __'___E3 ]3046 (Revised 4i11i96) Pate `� <br />