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SAir JOAQUIN COUNTY PUBLIC HEALTH ShjK VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION 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: (��p� �t y► n <br /> FACILITY ADDRESS: <br /> TANK ID #39 - lag�; TANK SIZE: _PREVIOUS TANK CONTENTS: 6q <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: P_LZ1r01�,wPn Ojovor. <br /> Address: RC) t 0 k :7 1 (A City: -Zip: <br /> Phone#: ( ��) ] j -�2 � Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: v ►D �(?T I.IN�A ��nln c rrcc GT i0�C <br /> Address: D � �7��Gj City: &,_t(At/Gi Zip: l�Q <br /> Phone#: (S_ 3 _) 0028'L g <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner equired by Cal EPA. <br /> Name: Title: rr *,� �-a� Signature: Date 1L„-)$-IJE_ <br /> SECTION 4- To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/ r piping. <br /> Facility Name: f (Cie, -re rd W e , fo p- <br /> Ci : zip:Address: ( JPO 23 <br /> Phone#: <br /> Date Tank Received: — / " 9? <br /> Name: /v• rB /S Title: f)eo Signav Date <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />