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LO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION i - Public Health Services Envirorunentai 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: 1ff�g177iGzE <br /> FACILITY ADDRESS: 4k a N• Qjnr 7aA-(%",rj am sas:rTa,3 CA _ <br /> TANK ID#39- TANK SIZE: l 5a o PREVIOUS TANK CONTENTS: SvAJ46-f-c�t�- <br /> LW <br /> war+k+k*w+t*+w+#*�*********r#*s+****+►*++***********s*s*rt*s+*#+******�+k**********rt****krt***+*****#s+M**s***»�**s <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> LW Tank Removal Contractor: N�r4 --- <br /> Address: City: Zip: <br /> L.. <br /> Phone#: ( ) Date Tank Removed: <br /> *srtss+**+s+s+++**►*,r*+*s**swws**+*�*+*s*++rts+++*+sss*ssss++sssrt++++w*w+ssss*s******+++**s****++s++:s+**+**ss <br /> 60 SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: O t i_ t1 CW t P M r<tiYr 554?j t`e <br /> Address: D. 3oK `t'SD City: 54n;AI,3D 2&V 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: Keith A. Tallia Title: Pres . _Signature � a/Date <br /> 4.0 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 /> 60 Facility Name: <br /> Address:3:::! v S1 t~ V try _ City: 5M A-Nb?-GA S Zip: 95ay 7 <br /> Phone#: (a Q 4 ) <br /> ppW�/N4q <br /> Date T-mg.Received: <br /> ttir <br /> Name: Keith A. Tallia Title: Pres - Signatu Date <br /> £H 23 046 (Revised 081131.99) Page 10 <br /> LW <br /> L.r " <br />