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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> \ <br /> FACILITY NAME: ��1j� Yo�gJ c'r S c�2 -- J—�C- , <br /> FACILITY ADDRESS: 2421 k,-19S4 1�,yZ <br /> TANK ID #39 - TANK SIZE: 10000 Gpl PREVIOUS TANK CONTENTS: p ies4 <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �—AL- "17 rJ C_ <br /> Address:gip ?Cr,6A,,, V_C� SuA'C yoo City: 1/o.cc�v, le Zip: X15(0$7 <br /> Phone#: 01 44Lp ylci a Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone N: ( ) <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: Ey' c k's., 1 c_ <br /> Address: a s_ _Po,✓,r _NCity: Lt �e Zip: 9y 80 <br /> Phone a: ( 5 Ic�, ) 33�_= 13`13 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9/11/96) Page 10 <br />