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SAN *QUIN COUNTY PUBLIC HEALTH SEROPES <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 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 />FACILITY NAME:Vy MINI r- <br />FACILITY ADDRESS: ���p - ri[� f is at'J� W l�� %__4" -- <br />TANK ID #39 - 3L%G" C' I TANK SIZE: PREVIOUS TANK CONTENTS:GA561A-65 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address:4i��g ujlw City: �l_l _ nm Zip: G SZ0_5 <br />Phone #: (1 l ' 1 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: ( } <br />City: <br />Zip: <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: <br />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 Name: <br />Address: City: Zip: <br />Phone #: ( ) <br />Date Tank Received: <br />Name: Title: Signature: <br />EH 23 046 (Revised 10/19/98) Page 10 <br />Date <br />