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SAI JAQUIN COUNTY PUBLIC HEALTH SER�a ES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD »r a##+rw»ars+»+i»r»rwwar»»»sr#++i ar•r»»»rrsasarsrsrsr»is»#»»rgartr rr»rar»r»swwwss»!#»r»»i SECTION 1 -Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. �1 FACILITY NAME: I—Ax�l FACILITY ADDRESS: TANK ID 1139- TANK SIZE: JAY' PREVIOUS TANK CONTENTS: r•aai#+rrrrsi+rraa++rr#wa•rr•rri+a#rlarra»waaa+rraia+aia»pairtarar4rrrr+aa»»aaallr++a»i•+»aa4r»+rw»aa4 SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: r Address: City: Zip: Phone p: ( ) Date Tank Removed: a r»ar#art rrr r+iia»ar•aiaa+r4w4r Mir++r4rir 4+»r»4►1!»a•Yaiw»r 4+lars»rir#ai wr+r»4»ars4ira+4 q ra a s ai» SECTION 3 -To be filled out by contractor"decon�tankbuktiing tank: Tank Decontamination Contractor: /�i'V / /7r� /f/' K/ � Address:— 3s� City: /_/�� Zip: 9- 561/'9 Phone k: (� Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date ra»r#+»rise#»i»a»r»sats»aas»war4»a»s»a»»»a»a»r»»r»sr»aars asrsrrt»»ia4»raiara»a»»s»4 i s» SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: Address: City: Zip: Phone q: ( ) Dau Tank Received: Name: Title: Signature: Date »•»»#+r ss++ra»»r»»aaara»a»ra»»r»»a+»s»»asa ata»sat»sacra»»ra»saa»ra»•r»»»s»»»»•r»»ws EH 23 046 (Revised 10119198) Page 10