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SAN JOAQUIN COUNTY PUBLIC HEALTH SEI2VICE5 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> t#rt#4Rlfkif ilitrtiki###rttk#k#rtrtiMliiMkrtilikkkkfkf#rtt#kk#t#t}tk WWtiti#WWtW##R#ki#i}##4##RM4W#R4k W4tM###}iR#44 <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: /�TQlIO �®��7' /_ ✓ n <br /> FACILITY ADDRESS: K�/ IA/ ICPf���MAiY �/u •f• Z4 <br /> TANK ID k39- TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2 -To be filled out by tank <br /> Nrremovalcontractor: <br /> Tank Removal Contractor: LeU/Ti $ / rO,W_6Ae&44- O/✓ /O <br /> Address: S �i4.r Qd' City:—Z Mly/ <br /> Zip: <br /> Phone <br /> Phone N: (_�WIO <br /> Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: _ Y29•41n_$ _�ZV12�er_9 <br /> Address: •yo,& G- 41'0,ya(e q City: /2eW1 Zip: lfQnpn� <br /> Phone N: C_VD) 4_,Q_:3 <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 /> Phone N: ( ) <br /> i <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> k}i#y4tt44W##rt#WW#iWk###i#W#W##i#rtrtW##rty###rt####}Wi4Rti#tt4tklik#f#ikW}iW#k##k}W}}#WW#ktttk#k#}ikirti}il## <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> i <br /> I <br />