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fi(T <br /> SAN JOAQUIN COUNTY PL412Cp AI�I d� ES <br /> ENVIRONMENTAL.HE Tgi slobF <br /> UNDERGROUND STORAGE TANK DISPOSITIC 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 /> FACILITY NAME: C lit OL)V'pNn L <br /> FACILITY ADDRESS:—_ Cl„ <br /> TANK ID #39 - jOS'Zff-0 ANY, SIZE: (P,C)C.3 PREVIOUS TANK CONTENTS:_C-OSO/th if <br /> ############WW+##+##+#+WWW++####+WW#WW++####+WW+######WWW+###W#W#W###+WWW++##W+###WW#W##+###WW####+#*#**W*• <br /> SECTION 2 - To be filled out by tank removal/contractor: <br /> Tank Removal Contractor: Ui evn 1- Co cT <br /> Address: P, 0, `E-03 City: Cod, Zip: <br /> Phone #: 1774 - 3 O Date Tank Removed: 9Z9 4 c <br /> W**W#****#*##WWWWW*++++*+*WWW+**##*#W#+WWW***#*#WWWW*W***++W+WWW***+W#W*W####W*****++WW****#+*WW*W**+*##*** <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank DecontaminationW�� Contractor: p-�� �A �C-( 9 /� <br /> Address: �. U . O� q-0 3 s�X City: ( r Zip: <br /> Phone#: <br /> Authorized representative of contractor certifying through signature below that the tank b n dec ted in an approved <br /> manner as required by Cal EPA. <br /> Name: Wt QrTitle: Signature- Date <br /> #*****#+##*##***+#*#**+*#WWW#**#WWW*W#+#+#+WW*#+#+**##W#+W#WW++**+*+WWW+**+WWW++**#WWW**##W#++W#W#W#+#*###* <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: � Sd..� .. i, cw-1. <br /> p <br /> Address: �C 1 A-2 2 Jj City: ` ._ ,1 Zip: <br /> Phone#: <br /> Date Tank Receivedd.,:q, <br /> Name: (7Nt4o `"l" Title: 5-lpe'u46rL- Signature: ;;IV",\ Date <br /> *#+**###+#**#+#++####+#WWW#W**WW*W*#+W+#+##+#+++W++#+W+#WW*####+WWW##+W###W#####+*#+++W#****W##**#**#*W W# <br /> EH 23 046 (Revised 7/10/96) Page 10 <br />