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SAN JOAQUIN COUNTY PUBLIC HEALTH SEK 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: k n0 N nt ( c-.-.n . <br /> FACILITY ADDRESS: (Sp <br /> TANK ID #39 - TANK SIZE: PREVIOUS TANK CONTENTS: >St- <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: LAAA.�OVN PUP^ l�p <br /> .20 Lv'r— <br /> Address: C7 ��C>>C �J (Qa City: r_lj.�y�t., Zip: <br /> Phone il: ( 50[ )._(91� L2c Date Tank Removed: „I-CA=a 9 <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: (A U(! Zip: <br /> Phone #: <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> mannerequired by Cal EPA. <br /> Name:VC.,grA Title: ,t�jc Signature: Date 11, 19-9 jS <br /> SECTION 4 - To be signed and dated by an authorh7 representative of the treatment, storage, or disposal facility <br /> accepting,tank and/or piping. <br /> Facility Name <br /> �' ?!FF23 <br /> Address: 352 - �2 ��• city. Cdt�fQK D Zip: <br /> Phone a: (�)_ 7 l <br /> Date Tank Received:- <br /> Name: <br /> eceived: �— <br /> / r , I / p <br /> Name: j�X15 Title: Pre__,�t0 �K Sig ate <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />