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SAN*QUIN COUNTY PUBLIC HEALTH SERPI:CES <br /> ENVIRONiMENTA.L HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 /> r <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID#39- TANK SIZE:_.., Q'� PREVIOUS TANK CONTENTS: �r <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: rr <br /> City: C Zip: -��J 70,x. <br /> Phone #: <br /> Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: ,� GGk.�- City; Zip: , <br /> Phone#: <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: 0 Title:?Z?CS1ZQ4af---�nature: to <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 /> Address; L5 19=- City: Zip: <br /> Phone#: { �f) ,fr-� <br /> Date Tank Received: <br /> Nam —tle: Signature. Date <br /> EH 23 046 (Revised 08/13199) Page 10 <br />