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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #+#rt####rt####+#########rt##rtrtrtrt##+###+#####W########W##rt##W###W######W#W############rtrt#W#####rt#######W#####rt <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: CA CA �cCtS`� WO:_-9 1om \rero e+nF � ,rstt�T <br /> FACILITY ADDRESS: _�Ci O Cl hiG�tU �C �yP CroSS S Ll�c c�. �cicnit <br /> TANK ID #39 - TANK SIZE: `t Sbb PREVIOUS TANK CONTENTS: ;p5_-j <br /> #+############+######rt##rtW#+#####W#########++rt######W##rtrt##rt#rt###rtrt#rt######rtrt#####Wrt*rt#########+##########+ <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:�� � GY�II (R7(\MeV\�G` �2CUiCe� i�'C <br /> Address:4ZZ6 r*Y er :0.1 LaS City: LYpl[ Zip: Ci S-3 So <br /> Phone N: ( '�D°1 )��7J—�� � Date Tank Removed: <br /> #####################################+###############+##########+###################rt#rt######+############# <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor:_��� o1n� ��( nV�(��� PY� �� _M - <br /> Address: U, 1 C) �cn ty\fwe r`C`OA •W dZ_ City:Zip: <br /> Phone N: (o109 s a - G`� SR, <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 /> 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: (�n � C-0 QL C T _,SLA� �ti _ I�� yv C <br /> Address: y041 s. r, city..i.� `oC h Zip: <br /> Phone #: (2: C ) (o3 Ll - 20 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />