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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .aas##r.#rtr}#sat}###arrtrtt}r}}}rtrtwstrtt4trW#rtrtrW}trtW}}}rrW}WW}#}##wrrt}rtwrrttrW}#trtrtrtrtt#}}}#rssrtrt.rrtsrtsrt#srss <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 ibis form is completed and returned. <br /> FACILITY NAME: G-fA±�, W AIZV)CE1 <br /> FACILITY ADDRESS: ark J\ J IAAR M-5 i <br /> TANK ID X39 - TANK SIZE: i °TPREVIOUS TANK CONTENTS: � <br /> ssttasst}s#s##swt}}#twit}#rrr}#ttt}i}trtWt}r#itW#w#twWrt}#W}}i#wWrtitwt}}rt#rtw}rtrtttt#rrtrtt#t}artt}##rtttrtsst#ttrsa <br /> SECTION 2 - To be filled out byyttank removal contractor: <br /> Tank Removal Contractor: k�L T EZ, � (Teo <br /> T U-4 n ,�- <br /> Address: `DO�'i -�V 1� ' City: OAtyk-e Zip: <br /> Phone #: ( ) 34-120 T2 Date Tank Removed: d <br /> r..r..........rt..wr}.rtrtrr..}i•ttWrtt}w.rtttrt#rttwt.rtt Wrtrtrtt W..rtt.rryrtrwtr..rtrr.rtr#wst}srtt..r.}###.}...rt.... <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": p p <br /> Tank Decontamination/ `lContractor: tOv �- � <br /> �TT &9- T eZ-l3-n �cv��t <br /> Address: yD�--T n�-IOIE ,>B-t} city: 6PP 'la'C'� Zip: 1 �'34-> <br /> Phone ,t: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner required by Cal EPA. , q <br /> Name: t Title: l5 '� Signature: Date 1 VI <br /> ..t.r...t## <br /> ............... <br /> tWW.....rt#rt#WWirWWrttr}rtwWrirtwWWttW#tt}#r}rtww}rttW <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 Na�m`e: ytt7r /WtE,,T �� <br /> Address: 5tbt0RCCity: tT",Wpe <br /> Ct �� '7Zip: 95W <br /> 3 <br /> 1 Q ! <br /> Phone #: ( � O) 6g \s g� n <br /> Date Tank Received: �� // �fr l nq reCfiye� <br /> `lame: �/�t"rJ, Title: T Signature: ate <br /> ....r..t. Y+`+ ,/>:i• '' ' '"}..trrt.rt.....rtt..#tww................... ......w r r.....................r.r. <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />