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0 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I - 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: �LsoO OCL <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: �i4SD2 . c <br /> ###++#+##t##t#rtrt+########%####fit###it#Wrtrtt4rt#*######rtrtW#rt###rt####i#rttitrtrtrt#t#iiitirtrtttrtii###trt###W#rtrt#WWW4W <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �S/J P�QY�p Q,. Co►2P <br /> Address: t"Llo 1 € . 5� sT City: &-k_QNAA Zip: �- <br /> Phone X: (Cjp�) 4a 16 Date Tank Removed:As&b 91 <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": N4 cgt4 <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone 9: ( ) <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 <br /> ateSECTION 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 /> Address: City: Zip: <br /> Phone x: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> El 23 046 (Revised 9/11/96) Paec 10 <br />