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a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVERONNI ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I- Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each'tink 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. �y. <br /> FACILITY NAME: T G}E ( 2 ' II ` t N�l���N � Tt ^� <br /> FACILITY ADDRESS: 2 4©c�( S O U y j., ktc V N�'1 <br /> TANK ID#39.23;Mpt 7 0-)b t(-TANK SIZE:_3,C2QO PREVIOUS TANK CONTENTS: Vl LSLSL NU. 2- <br /> SECTION <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City' Zip. <br /> Phone q: ( ) Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: 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: Title: Signature: 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 /> I <br /> Phone/t: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> ##########w######MM####w#w#wM####M#ww}M####}#+#+##}w###M#M#######w#MM#M####+####w#+#M######+##########M## <br /> EH 23 046 (Revised 08113/99) Page 10 <br /> J <br />