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SAN JOAQUIN COUNTY PUBLIC HEALTH Shn VICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*********************************************************************************************************** <br />SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shalt 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 returne__//d--. <br />FACILITY NAME: (.f % ��(. p i4, -7r S AIZ& <br />FACILITY ADDRESS: <br />TAN,9D #39 - EVIOUS TANK CONTENTS: <br />TAN, <br />J � y� <br />SECTION 2 - To be filled out by m removal contractor: <br />,'PF <br />Removal Contractor: J - G S E2 ✓ CE_„S' <br />Address: -S-27 AV City: Zip: i372 -,,O <br />P, PE <br />Phone #: (SS`)) t) y y - 173 C Date T iak Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address: <br />Phone #: ( ) <br />City: <br />Zip: <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 <br />Title: <br />Signature: <br />Date <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting piping. <br />FacilityName: ,f av logy C6Ai 2u j <br />Address: 1-3738 $1 oy E2 AVE City: F; Ani A Zip: '92-33,s— <br />Phone <br />233s— <br />Phone #: (90�) s1o0 <br />Date 4�w*yR eceived: <br />Name <br />Title: <br />Signature: <br />EH 23 046 (Revised 08/13/99) Page 10 <br />Date <br />