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SAN JeAQUIN COUNTY PUBLIC HEALTH SERrkES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />#wr*rtrWrwwwrrr+##rWw#rrt#r#rt###+r#rwrwww#r»##r#w#wwW+iwrr##wwrt#+##r+w+W+####++++++wwwrWWrw»#++++*+#rtw#ww#www <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: �iaiV 4- 5&11A AA -11 <br />FACILITY ADDRESS: 1_JTV <br />TANK ID #39 - <br />TANK SIZE: 7i PREVIOUS TANK CONTENTS: <br />#r#Wrtr#i+###wrW+wWr#w+Wr##wr####w+#+###rtwwwwi+ii+##rr#»i###w#Www#WWwwww»rww+wWrrwrtrwWw»Wriir##+###WWW#####w <br />SECTION 2 - To be filled out by tank removal contractor: g�% ru7l��pd <br />Tank Removal Contractor: G J <br />Address: City: <br />Phone p: <br />Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": n/I,�q —ItWvK Jxct5 hc(2 <br />Tank Decontamination Contractor: <br />Address: <br />Phone k: <br />City: Zip: <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 />w+#r++p*r+#+rr+rr##r#r»rrr*rrtw*##ri##+#r##r#w#rt+#rx#rwrtwrr*rwrtrwwwwwwwrwr+rtrtr»rwwxw»rrr»rr»#xwrr+rri»*»#rx <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: <br />W.TTl <br />Phone q:( j ) qZ i9 <br />Date Tank Received: <br />City: Zip: <br />Name: Title: Signature: Date <br />w*w*#ri+rr+rxwr#}rwrrWrrr+*rw+rr»+ri++rrw#r+#rrtrrrrr»rrr+*ww#w»##rrt#r#+rt»#rww**w#rr++rwr#»rwwrr*xrrr»»++w <br />EH 23 046 (Revised 10/19/98) Page 10 <br />