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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rf*i}rrt}fktf*t}f#f*�iraii«Y*«;#44+4k*44**#}*r;r#*rr+rW#ff#rr###Y##i#W#rfM#«f4+*ff4ff*!!*f*k#ftf#liff+itf!« <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 /> FACILITY NAME: _. <br /> FACILITY ADDRESS: DIA 3 �_ �: �N9 <br /> PREVIOUS` CONTENTS: ile-j e <br /> TANK ID#39- - d RP y <br /> .tt Wlkfft#;fkttlkttYkraft+f**kii*;;+##+***f4##rYrt*kYf#rtrW+#*YY###rr WRk�r+W###f#+k#f+**r4+*#+f+i++iii#44Yir}i <br /> ECTION 2-To be filled out byAonieremoval contractor: <br /> ' cte<< <br /> Removal Contractor: <br /> v <br /> Address V o 'ft2 CVS a'J r�w L 1p.��iy..isl.�11A. <br /> '711,! City: w � Zip: C&0�( <br /> Phone t ciao ) g 7 a V e 3 ' Date Tank Removed: <br /> ••illi+kiftl Yfi«kil4kltr#;#i}i#;4;##rtYr#4k}r##;;;*kR;ir####i#+####4####rt4###rtFYi#####rY##f##ri*###;rri#•*+l <br /> SECTION 3 -To be filled out by contractor "decontaminating IemMIL?�V s <br /> X-Agi-Decontamination Contractor: uo�� Itit'tVs\lt,t.�1H ��w�'C't <br /> Address: ( L��_7 I �.GI City: 4 .to L- ^ zip: 9�1 Y of] t� <br /> Phone B: (_ o &A- Is �3 <br /> Authorized representative of contractor certifying through signature below thatthe4ok has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title:_,__, Signature: Date <br /> ! ilii*;*til*##rilfi#*�i��l4r«ttr##«li+«+44rY##}k4r;k4ii*««ltYll+4k*trf#4f44#1«ir++;+++##*#;l;lr+WYl#li;lY♦+# <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 p: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> •4r*;;ill#4rriYr#r*#frit«##rrrr4###ir#rtr##flfi#rtr###+#f fi44f###!lfitrl#4Wf++#;kltlltii+Yi#####rl4lilli+#r <br /> 1 <br /> i EH 23 046 (Revised 08)[3/99) Page 10 <br />