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SAN /AQUIN COUNTY PUBLIC HEALTH SII .tris <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DLSPOSMON TRACKING RECORD <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: ATZ C (' N, M r� <br /> FACILITY ADDRESS: ;�U 1 IA )�, 1=-C Z 1- <br /> TANK <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: t t C U -C u L l\0 1 <br /> Address:2,U A O 1-,5 C:z,a MU N)l !�17 City:5 i 0 CKZ Zip: �rJ�.0 Cl <br /> Phone#: (2U4 ) qA3 - O 5�_Dam Tank Removed:?g- L��� <br /> SECTION 3 - To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor- E�- <br /> Address:? �. a A�-� b L� 1� City:]�1� )�� Zip: g �O <br /> Phone#: ( 5 \C) <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: 1- L <br /> Address: 2. 5 �� LV� Citra.\C�\\`W N� Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />