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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />w##w++#w##++####+###++*w#+***#+*##+#**#+##*+*#w+*######+#+#+##+#+#++#w++###+*+##+#+##www#*#w*+#+#*##+++#+++ <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. j <br />FACILITY NAME �— kc_-.) <;,> t t C 2 t V! GF_ <br />FACILITY ADDRESS: <br />TANK ID #39 - TANK SIZE: aL PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out byfeot-emoval contractor: <br />Tank Removal Contractour"'C29,F� <br />Address:_ <br />M410 4) �3'i = <br />City <br />: Zip:��?�� <br />Phone N: Date Tank Removed:r9 <br />+++#+##++++#+#*##+*#*w+*#+#+w###+*#+*+w#+##+#w++w+#++#+w*++++*w+++++++#w*++##+#*++ww++++++www++*#w#+#+++w++ <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />1 PC - <br />Decontamination Contractor:, <br />Address: Al, U ttjt 0 <br />Phone #: (roc? ) <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: <br />Signature: <br />Date <br />SECTION 4 - To be signed and �dantedauthorfzed representative of the treatment, storage, or disposal facility <br />accepting tankand/ <br />FacilityName: <br />Address: S� W� — City: Lt2g ~t Zip: <br />Phone #: ( ) <br />Date Tank Received: <br />Name: Title: Signature: <br />Date <br />#*#w**w#*#w*#####*##*#*#*+#***+ww+w*+##w+w#++#ww+##*w###+#*+*##+#ww*+##+www*#+ww*++##www#www*wwww+w*w+#++ <br />EH 23 046 (Revised 08/13/99) Page 10 <br />