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S�JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ++rt+*+w+r+Wrtr+*#w+4rtw4w»+w#W*+rtrtt}+}rtwrtrt+rt#+t4W+rtW*ttatrt4+t*W+4+#rt++w#+rt+wrt++4+r+rtrt*#W4wt4+t4+wtrt44:rtt+rtt+ <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 /> FACII.ITY NAME: <br /> FACILITY ADDRESS: <br /> - <br /> TANK ID7q39 - ANK SIZE:�QQ PREVIOUS TANK CONTENTS:��O sZUn< j <br /> *rtrt*+++#+#rt+twwrt####rtrt+*+wWw*w+}+W*wrtrt}*+rt#w*+w**#*rrt+rrt#tstwrt+*+ww+t*twr#wrt}W#+#*++rt+w#rtrt#wWrtrwrtrt#++w4++* <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. J <br /> Address: c�- <br /> City: <br /> Phone#: ( , 7 5' �/ Date Tank Removed: <br /> #++W+4�ktrtrt+*rtrt#*#wrttrtWrt4+}}W*t**rrt#rt#w*#*+}rt»rtrt#4+#F#+rtrtrrt+#rt##*W4+rtrtrtrt+rt+rtrt#t+WrtWrtrtrt#44++4trtit4##4rt4#4# <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> "Tank Decontamination Contractor:_ <br /> Address: ! G �j�p <br /> Phone#: ( -31112 L��l <br /> Authorized representative of contractor certifying through signature below that the as been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> / <br /> Name: Title:_ Signature: Dat <br /> e <br /> #+}rtrt+rtrt#**rt#*rtrt*w+t*++#*t*+*4w#WwW*+Wrtrt*rt4Wrtt+*rtrt»t+*++rtrt*++ rtrt++ *rtW*4 rtrt+rtrt rtrt*44#rtt#4#i+rtrt#4##* <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:, All Z see <br /> �7 �/?-?,aX1s, <br /> Address: / 2 6909 Ci ry: <br /> �/4101-O <br /> Zip: 9-31-� <br /> Phone N: <br /> Date Tank Received: <br /> Name: 1 f L4—Title: 7 Signatur . _ Date _L <br /> }*#wt#tWrt+#trt4##w#t##trtrtw4+rtrt+rt#}#+4#rrt##+}rt*4#*rt#+wort*}41+rtrt#}rtrt+rtrt#+W#rtrt*t4#rtrtrtt4#+4i*4+4w4rtrt#rtt+#w4w4 <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />