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SAN j*QUIN COUNTY PUBLIC HEALTH SERO -S <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TAMC 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-Vlq (K1c�1 <br />FACILITY NAIvfE: <br />VkAF L T <br />� S I I\ l -A LS <br />W <br />FACILITY ADDRESS: l 1 <br />TANK ID #39 - 5j S?il7 TANK SIZE: _ oo PREVIOUS TANK CONTENTS: GLJ k�D� L <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: \� i 'f S, f (5`� r City: -` S Zip: 1 ��5 <br />Phone N: (��) �Z. ` �S Date Tank Removed: 3 <br />########wwrti##*ww#ww####irfi#ww##*iw##Www*wwwrt*w#*#wfirtiifiww#rt*i#*ww#*...wfiW#w#**#####fiWiwrtww##irtWw####w##### <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: C 2 �� q c� City: M043jo Zip: C -A 5 3S 1 <br />Phone <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner asp—regquuiired by Cal EPA. (� <br />Name: I t /ct l F' Title: �e,� ` L b'S^ Signature: v Date <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 <br />City: <br />Phone t1: <br />Date Tank Received: <br />Zip: <br />Name: Tide: Signature: Date <br />r#fiw#fi##ww##wfifi#w##w*Wwfi##Www**###fi#i###fiww#ww*rtwwfi#ww#fiwi##fiW#wwww#wfifiwwfi#####fiw*##W#######rtw##w##*wrti## <br />EH 23 046 (Revised 10/19/98) Page 10 <br />