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4.06-1998 8:58AM FR$TAIT SACRAMENTO 916 635 2606 P. 12 <br /> • <br /> SAN JOAQUIN COUNTY Pt1SLIC HEALTH SERVICES <br /> &WIRONNIENTAL HEALTH DVMION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ryNNNWNPNNN##!###W!##!ki##!#WNx#MFR##a#wNlMWx######a##q##rrW#wWNxkNwMNl M##+#M###rwwaWr CdCh tank affixed SECTION I -Public Health Services Environmental Health Division T2*Tradcmg Slue shail aceoY <br /> with its site identification number. The Tank Traddng Shoet is to be rewmed to Public Health Services Environmental Health <br /> Division within 30 days of acccptaace <br /> of the tank by the disposal or recycling facility. The permit bek rr is responsible for <br /> easuriag that this form is completed and returned. <br /> FACILITY NAME: Cel t- t r`7 2 1 <br /> FACXLX'fYADDRFSS: T7303 Cf <br /> TANK ID N'34- <br /> TANK SIZE: 12 t_ PREVI0175 TANK CONTENTS: vn fr rxof<vI <br /> #s##rr###w+WWWNNxMWNWMNNMMwN##r##wWwWkNNW######+rgwWWgWMxWWWwNMMxwMxi#!#####WWWWNWMMMNWNlW!#w#!r#rrlWawr+ <br /> SECTION 2 - To be filled out by tank removal contractor! <br /> Tank Removal Contractor. <br /> Address: City. Zip:_ <br /> Phone#. Daze Tank Removed: <br /> rIrWMNWx###!##M#r##WW#kaNW#NNN!#"MMM#rawwWwkxNMMq#MMi#M####!wr###W#kWwW►gxWrN##MM#####WWWWkWW#WWNlMWWW <br /> SECTION 3 -To be filled out by contactor "deeontampaatft tank": <br /> Tank Decontamination Comtaetor. <br /> Address: City' Zip. <br /> Phone <br /> Authorized representative of contractor certifying thmgh signature below that the tack has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: <br /> _ Title: Signature: Date_ <br /> ##k####r#r##q#kaNWW#rwwWWNNMxNwWMM#irr#rWwlxWiFxNMNxgxNiMNMMNrkxMrNM#MWprr#r#ww#yeNwwwwxxrNMWrMMN##!###ww#N <br /> SECTION 4 -To be signed and dated by as authorized representative of the treatmem,sterage, or disposal facilitY <br /> accepting tank and/or pip»ng. <br /> PmEty Name: <br /> Zip: <br /> Address: Clty: _._ <br /> Phone d: (--- <br /> Date <br /> TDate Tank Received: <br /> Name: Titer. Signamtte: Date <br /> ++####+WW#aWN#wWwgww#k WwNWWNwMk#!x#r#r!#wNWWNNxNNxxNNNgNNNwWWWNNMrxNMMNxM#lrra#r###rr##wWWMWMwWrr#W#wW <br /> EH 23 046 (Revised 9/11196) Page 10 <br />